Book Review

Mount Misery

N Engl J Med 1998; 338:1476-1477May 14, 1998

Article

Mount Misery
By Samuel Shem. 436 pp. New York, Fawcett Columbine, 1997. $24. ISBN: 0-449-91118-7

A roman à clef — from the French, “novel with a key” — is a novel that thinly disguises real people and real situations. It is a fictional representation of reality, first popular in 17th-century France, that is still often used to emphasize a social point. Stephen Bergman, an accomplished author whose pen name is Samuel Shem, is a practicing psychiatrist in the Boston area. Mount Misery is his most recent roman à clef — a farcical novel about Dr. Roy Basch's first year of psychiatric residency. The thinly disguised Boston psychiatry scene, in which famous and infamous physicians, hospital staff, and administrators are portrayed, is made even more plausible by interspersing the names of real (nonfictitious) people such as Otto Kernberg and Alan Dershowitz, thus making this novel appear genuine.

Shem is a gifted writer, psychologically insightful, often hilarious, and judging by his sensitive portrayal of some of the patients in Mount Misery an effective psychotherapist in his other profession. Unfortunately, the black humor and hyperbole with which he describes doctors, mental patients, psychiatry residents, and staff at Mount Misery is often cruel, misleading, and only occasionally sensitive. Clearly, these distortions are fair game for a novel that is, by definition, fiction. Unfortunately, because of the stigma and myths surrounding psychiatry and its patients, the use of the roman à clef technique makes Mount Misery easily mistaken for truth. Does Shem have a cause? The answer is found in the March 31, 1997, Boston Globe, which quotes Shem as saying, “I feel the same sense of outrage about psychiatry as I felt about medicine when I wrote House of God.” The blurbs that adorn the book jacket add to this illusion: “When a psychiatrist speaks the truth we have an exceptional book.”

The book would be hilarious if it weren't for the patients who suffer from psychiatric illnesses. Sadly, Mount Misery takes another whack at such patients, their illnesses, and those who try to help them. Stigma continues to plague psychiatry, and it is unfortunate that, however unintentionally, Mount Misery perpetuates this. Unrealistic limits on insurance coverage for psychiatric care have now become the standard. Every form of treatment, be it psychotherapy, pharmacotherapy, behavior and somatic treatments, or combinations of these, is restricted and has yearly as well as lifetime limits that are unrealistically low. Psychiatric care is carved out, carved in, and carved up. Chronically ill psychiatric patients are rarely afforded the medical coverage that patients suffering from other chronic diseases are. Even some religious and social movements single out psychiatry and psychiatric patients for special attack. Yet, the prevalence of psychiatric illness is high by any standard, and the cost to society is immense.

The National Alliance for the Mentally Ill (NAMI) has targeted stigma as its principal challenge. The existence of large citizen organizations, such as NAMI, the National Association of Research in Schizophrenia and Depression, and other lay organizations is a relatively new phenomenon and may help dispel the myths that surround psychiatry. Books like Mount Misery do much to undercut these efforts. After the novel One Flew over the Cuckoo's Nest (by Ken Kesey. New York: Viking Press, 1962) was released, it was only with extreme effort that psychiatrists were able to convince severely depressed patients to agree to undergo electroconvulsive therapy. This often life-saving treatment was shunned by many, and legislation was even introduced in at least one state to ban the treatment altogether. Mount Misery manages through hyperbole to trash all forms of psychiatric treatment except “connectedness.”

The book follows Roy Basch, M.D., as he rotates through the various buildings of Mount Misery. Each building represents a different psychiatric treatment that Basch is to master. This block-rotation model is in itself an antiquated model of training. Most good programs now follow a more integrated longitudinal approach that emphasizes continuity of care. Basch's training is even more distorted because treatment is determined by the attending psychiatrist, whose force of personality and rigid adherence to one type of treatment, no matter what the patient's diagnosis, determines the therapy. Force of personality rather than scientific evidence carries the day. Shem even depicts the psychotherapy of Basch's outpatients as evolving from rigid nonsense to more of a discussion between chums than a physician–patient relationship. Boundary violations are rampant. Even the patients do not escape Shem's wit: he writes of “the . . . skipping manics, the herds of trudging depressives, the paranoids darting and peering, tree to tree. . . . ”

The book itself seems to be presented in two parts. The first part is hilarious, with Shem painting effective pictures of the Hitler-like Heiler, the mute psychoanalyst (A.K.), the pharmacology police (Cabot and Winthrop), and the wise blue-collar switchboard operator (Viv), the array of bizarrely crazy patients (the lady who eats metal objects), the predatory administrators (Lloyal von Nott and Nash Michaels), and the very confused and disturbed psychiatric residents — a collection of characters worthy of Nathaniel West. Shem, however, quickly turns to describing what can only be considered a slaughterhouse. The humor turns to violence and horror. Brain surgery is performed on living dogs by trainees holding a scalpel in one hand and the anatomy book in another; suicide, murder, and natural deaths abound; and sexual bacchanals are the theme for the staff, faculty, and trainees. Psychiatrists are portrayed as heartless Freudians, money-grubbing, sex-crazed analysts, and maniacal psychopharmacologists who would make Nazi physicians proud. Social workers are depicted as ineffectual, and behavioral therapists as perseverating; even treating children with medication for severe attention deficit disorder is trashed.

And so the myths surrounding psychiatry continue, the stigmatization of psychiatric patients gets another boost, and “connectedness” replaces common sense. Thank you, Dr. Samuel Shem.

Peter M. Silberfarb, M.D.
Dartmouth Medical School, Hanover, NH 03756