Adam Stern, MD’s, book makes the case for a more human psychiatry.
by Adam Stern, MD; Harvest, 2021
320 pages; $15.82 (hardback)
Reviewed by Carlos A. Larrauri, MSN, and Michael Ashley Stein, JD, PhD
Adam Stern, MD’s, memoir, Committed: Dispatches from a Psychiatrist in Training, should be on any aspiring mental health clinician’s bookshelf. Readers will benefit from wisdom shared from numerous patient relationships throughout his psychiatric residency. For example, Stern poignantly observes that at the core of the psychiatric field is an intimate understanding of the human condition and the call to help individuals thrive “in spite of, or even because of, the immense challenges they face.” His apt summation of the clinician’s duty and his patients’ challenges demonstrate a deep understanding of his profession.
Furthermore, Stern’s candid confessions of struggling with imposter syndrome as a newly minted resident and his subsequent transformation into a full-fledged psychiatrist authentically portray the exacting journey toward becoming a clinician. With adeptness and compassion, he crafts a series of poignant patient vignettes that reveal the struggles and bonds forged through the healing process and leave readers with insight into the unique therapeutic relationships formed between doctors and their patients. Ultimately, the memoir casts fresh light on the inner workings of psychiatric residency and leaves no doubt that Stern is a psychiatrist who cares profoundly about his patients.
Committed also contends with significantly pressing and challenging bioethical issues in psychiatry. For example, when Stern is confronted with the disconcerting reality that, at times, psychiatrists and other clinical professionals are tasked with initiating involuntary treatment, he highlights his moral dilemma. He confides, “I hated the idea of working against the patient… treating anyone against their will seemed counter to the image I had of what it meant to be a doctor.” Stern genuinely grapples with the ethical implications of involuntary treatment and what it means to be a doctor while demonstrating a mature awareness of potential countertransferential factors.
The practice of involuntary treatment is fraught with a history of abuse and maltreatment. Even today, receiving involuntary treatment can be traumatic for patients and cast a negative emotional valence that biases their attitudes toward mental health care and professionals. In turn, this bias affects engagement and adherence with treatment—in many cases, to the patient’s harm. Committed does not back down from addressing aperennial and contentious quandary within the field and among patients living with psychiatric illness, and it gets to the moral heart of the matter for the aspiring clinician.
Moreover, Stern is initially alarmed by electroconvulsive therapy (ECT), but eventually becomes accustomed to the practice: “The idea of electroconvulsive therapy frightened me, but the truth is, I had never seen it.” Modern ECT has come a long way from the portrayal popularized in One Flew Over the Cuckoo’s Nest. The evidence base for its efficacy, safety, and limited circumstances is well-established and robust. ECT can be lifesaving and far less risky than alternative somatic treatments or no treatment when indicated and appropriately administered. Still, the practice is not without controversy because of the poor education the public and many medical professionals receive regarding ECT; the checkered history of its overuse and abuse; lack of understanding of how it works; and the risk of severe memory loss as an adverse effect of overtreatment.
In Committed, Stern’s patient credits ECT with saving her life, and he is grateful that her experience with it was positive. However, for a vocal minority of patients, the costs outweigh its benefits. Ultimately, the best advocates for and against ECT are individuals who have experienced it, and discussions regarding its utility must balance doctors’ attitudes with those of patients, including those who may have opposing views. Nevertheless, in his memoir, Stern’s treatment of ECT highlights the ethical complexity of another often debated and provocative treatment in the field and for patients.
Committed is an honest and thoughtful portrayal of one person’s journey to becoming a psychiatrist. Committed also features Stern’s genuine struggle with the more controversial treatments and nuanced bioethical issues in the field. In the end, Stern learns his most valuable lessons from listening to his patients. His illusions of the ideal psychiatrist give way and make space for hard-earned truths about connecting and committing with individuals, teaching him how “to purposefully keep moving forward.” At its best, psychiatry’s journey continues to be guided by listening to patients. May this conversation continue.
Mr Larrauri is a member of the National Alliance on Mental Illness Board of Directors in Arlington, Virginia. Dr Stein is executive director of the Harvard Law School Project on Disability in Cambridge, Massachusetts.