Misery's Company

Mount Misery is a lacerating caricature of psychiatric training, psychiatrists, and the institutions and systems where psychiatrists seek training and psychiatric patients seek help.

Roy Basch begins his residency at Misery eager to learn to understand people and how to help them. Instead, he learns that "worse" is "better" and "better" is "worse," that there is a "sure" formula or algorithm but he must decide which it is. He is lucky, he is only confused to the point of suicidal depression. Others drop out, go crazy or successfully suicide.

His year begins with the suicide of his training director and ends with the trial of a faculty psychoanalyst for repeated and extended sex with patients. He learns from a world-class borderline expert that good is bad and bad is good, that everyone is borderline and must be punished in order to heal. From a drug cowboy he learns to apply algorithms for diagnosis and drug treatment and how easy and necessary it is to change diagnostic formulations to receive the best insurance payment. From the icy, note-taking psychoanalyst, he learns that no cigar is ever "only" a cigar and that notes should be in two columns, one for what the patient says and one for what the analyst thinks and feels.

During the year, Misery changes the names of its buildings from such thought icons as Emerson and Thoreau and such traditions of learning as Heidelberg East and West to Toshiba and finally to the names of insurance and drug companies and health plans.

In a telling digression near the climax of the novel, Shem warns that as psychiatrists become drug pushers instead of listeners, "The actual work with human beings will devolve to the ones better at it, the nurses and social workers and mental health workers and alcoholics and addicts in recovery and pastoral counselors way down the flow chart of Misery."

Those who are "with patients day in and day out, through chance encounters and common sense" are the real healers: "Like the basically cheerful often dark-skinned workers in Buildings and Grounds who talked with patients while emptying the trash or mopping the floors or cutting the grass."

Roy Basch learns from his patients and his flailing colleagues that he must stop copying others while trying to do it better. As he moonlights in an emergency room late in the year, as much for relief from Misery as for additional money, he realizes that, despite Misery, "my vision has broadened. Instead of seeing just bodies, I was seeing people, reading people, sensing in people's faces and postures and words and in the intangible stuff, some truth about the person, not only in terms of each life, but in each as part of any life, of life itself; the sorrow behind the smile...even the smile behind the sorrow."

Like Basch himself, Misery gets more chaotic during the year. "The algorithms, the decision trees, the boxes adangle from other boxes were banging into each other, coming to rest at weird angles. Just as doctors were no match for businessmen, the hospital was no match for the insurance industry. The industry now more or less owned the hospital, and thus owned the patients too. Talk was no match for drugs. The industry would not be paying for talking any longer....Those who could pay, could talk to a therapist; everybody else could be handed a drug. Most psychiatrists would be pill-pushers. It would be great for the drug industry and the insurance industry. They would be making a lot of money....Risk, once taken by insurance...would now be taken only by patients and doctors."

"Psychiatry," Shem ruminates, "succumbed to the medical model: diseases, diagnosis, and drugs." As a result, "Shrinks had fallen prey to the very thing they were supposed to heal in their patients: the isolation of one human being from another, and the violence of one human being toward another." The institutions set up to heal people were replicating what made people sick in the first place, "all these Miserys of the world." "In this, allegedly one of the most human specialties in all of medicine, human beings often seemed to matter least. Perhaps it was inevitable."

Basch looks back and sees "how a lot of the world experts in Misery acted as though they truly believed there was a medical treatment for the suffering of the soul." With two billion prescriptions for Prozac written during his year in Misery, what if "some of the Prozacians had seen their sex drive wither? Well, wouldn't a bit less sex drive be better for society, as a whole, in the end?"

Given the prurience in Mount Misery I might agree.

Ed_Rudin@macnexus.org