Book review

‘Falling into the Fire’ by Christine Montross


In his recent book, “Saving Normal,” psychiatrist Allen Frances argues that far too many mental-health resources are going to the group that needs it least, the “worried well.”

That’s not a term one would use to describe the patients in Christine Montross’s “Falling into the Fire,” a book that alternately intrigues and appalls.

Montross is assistant professor of psychiatry and human behavior and codirector of the medical humanities and bioethics scholarly concentration at the Warren Alpert Medical School of Brown University. Her practice has focused on psychiatric inpatients, people in the throes of severe mental illness.

The pseudonymous characters she describes in “Falling into the Fire” are (among other complaints) catatonically depressed, consumed by homicidal thoughts, given to ingesting knives and scissors, or prone to seizures that resemble epilepsy but have no neurological cause. Montross’s thoughtful, discursive musings on their conditions and her sometimes faltering attempts at treatment evoke Oliver Sacks’s chronicling of neurological oddities.

Among those Montross fruitlessly struggles to help is a man in his 30s who suffers from the delusion that his face is scarred by acne. Over the years, Eddie has concocted painful home remedies, including scouring his face with sandpaper, and undergone dozens of dermatological procedures to fix what isn’t broken — interventions whose net result is to make him look worse. The psychiatrist diagnoses him with body dysmorphic disorder, but he resists the indicated treatments of Prozac and cognitive behavioral therapy. She can’t do much but listen to him with sympathy.


Montross doesn’t touch on the ethics of Eddie’s dermatologists, who apparently take his money — $50,000 and counting — to fix imaginary ills. It’s an odd omission, especially since she does ponder the ethics of surgery with regard to another (fortunately rare) group of patients: those suffering from body-integrity identity disorder, or BIID. These are people who regard their perfectly normal limbs as “alien” and plead for amputation.


BIID, Montross notes, has been compared to what is now known as gender dysphoria (the clinical term for transsexualism). For transsexuals, sex reassignment surgery is sometimes the treatment of choice. But elective amputation, though it does (bizarrely enough) alleviate suffering, leaves Montross feeling “great discomfort,” not to mention entailing various social costs. In this case, she writes, surgery may be a matter of “treating a symptom without understanding the disease from which it comes.”

That, it turns out, is a recurring dilemma for psychiatry, as Montross is humble enough, and honest enough, to admit. She frequently finds herself charting symptoms without comprehending causes. “We do not understand why schizophrenic patients are plagued by visions and voices,” she writes. “We do not know why some deep depressions do not relent.”

And yet, she writes, “We try to alleviate suffering even if we don’t fully understand the mechanisms of what we prescribe.”

This makes psychiatry a risky business, as Montross concedes. In one memorable case, a woman named Annie admits herself to a psychiatric hospital because she is having frightening thoughts about harming her 15-month-old son. Reaching the correct diagnosis, Montross knows, is a matter of life and death, and requires a sometimes elusive level of precision.

If Annie is hallucinating, she is psychotic and leaving her alone with her son could prove dangerous. But if she is instead imagining these murderous scenes, she likely has obsessive-compulsive disorder and “the treatment would call for her to spend more time with her son in increasingly distressing and anxiety-provoking settings.” In this instance, at least, Montross seems to have gotten it right.


One weakness of “Falling into the Fire” is Montross’s insistence on alternating her case studies with passages of memoir. Descriptions of her life as a happily partnered lesbian with two healthy children seem tacked on, even if they do give her an opportunity to wax literary and celebrate the randomness of luck.

More useful is her citation of the wisdom of one of her mentors, W. Curt LaFrance Jr., a Brown University neuropsychiatrist. Sometimes, he tells her, instead of taking potentially destructive action, a psychiatrist should focus on cultivating a deep empathy for his patients’ lives.

“I must stand at the edge with them and peer over into the fathomless depths,” Montross writes. “If I tell my patients . . . that this life can be a tolerable one, . . . I must look at what I am asking them to endure and I must look it full in the face.” That is what “Falling into the Fire” attempts to do, and, at times, squeamish readers and inadequate beings that we are, we will want very much to turn away.

Julia M. Klein is a cultural reporter and critic and a contributing editor at Columbia Journalism Review. E-mail her at or follow her on Twitter at @JuliaMKlein.