In a House of Dreams and Glass: Becoming a Psychiatrist - Softcover

From Peter Kramer, M.D. (author of Listening to Prozac): "Using his finely developed talents as writer and participant-observer, Dr. Klitzman captures the feel - the fascination and bitter frustration - of that unique rite of passage, the big city psychiatry residency, in a time of AIDS, homelessness, and shifting models of the mind and its ailments.

From Ned Rorem: "It is a sort of Magic Mountain in reverse: the insular ! machinations of hospital living are related not through the patients but through the staff. The result is at once painful and cheery, instructive and entertaining, depressing and uplifting, sentimental and hard-boiled. It is, finally, the unflinching depiction of both the fragile vanity and the solid beauty of the psychiatric profession in America. Robert Klitzman's book is an engrossing and meticulous recital of his three-year residency."

From review by Kay Redfield Jamison in The Washington Post Book World (March 19, 1995):

No one who has become a psychiatrist or clinical psychologist would argue that the training process involves learning only about the diagnosis and treatment of psychopathology. Rather, the training is also, an importantly, about the understanding of one's self, about the role - and limitations - of one's own mind, experiences, character and temperament in comprehending the nature of patients' symptoms and life stories. Clinical training is ! a complicated threading together of scientific and medical ! understanding, a changing awareness of self, clinical supervision that can range from the absurd and awful to the kind of lasting influence that great clinical teachers always have, changing beliefs about what medications and psychotherapy can and cannot provide, and intense years of increasing responsibility for often severely ill psychiatric patients. In the end, it is usually the latter that are the most forceful and compelling teachers. Two recent books, In a House of Dreams and Glass by Robert Klitzman, and A Different Kind of Listening by Kim Chernin, explore the very different types of experiences that the authors had in pursuing their professional goals. In a House of Dreams and Glass is a psychiatrist's account of his residency in a New York teaching hospital. Klitzman weaves his book around several case histories of patients and gives an engaging, direct portrayal of the stresses, aggravations and rewards of clinical training. In the process it shows the author'! s progression from an idealistic young doctor to a self-doubting, then deeply skeptical and, finally, practicing psychiatrist. The story of his transformation is well worth reading. Klitzman shares his frustration at the reductionism of his psychopharmacology supervisors, as well as the rage that can develop on the part of medical and nursing staffs toward certain kinds of patients with severe personality disorders. He also discusses at length the psychological stresses involved in assessing suicide risk, the difficulties he experienced in lost sleep and shaken self-confidence after one of his patients actually attempted suicide, and the problems that come about from the subjectivity of psychiatric judgment.

While I feel that Klitzman overstates the degree of subjectivity involved in psychiatric diagnosis and treatment, there is no doubt that such subjectivity is a very real problem. He describes its consequences: "In medicine, for example, failures were ascribed t! o patients' high sodiums or low potassiums. When disaster ! occurred in psychiatry, I had nothing to blame but my subjective impressions that had led to my decisions - not objective factors."

Klitzman ultimately directs a great deal of his anger at his clinical supervisors who, he felt, from the beginning, engaged in "a process of equating residents [doctors in training] with patients that would come to shadow much of my training." His accounts of the inconsistencies in diagnostic and treatment practices that he encountered in his different supervisors gives a realistic picture of what can happen when a teaching hospital encourages a diversity of theoretical orientations, but no cohesive clinical viewpoint is presented. Klitzman reserves particular spleen for the psychoanalysts, whom he regarded as condescending, aloof, unsupportive and cold: "Those who most talked about and professed the importance of feelings - the psychoanalysts - were often the coldest and least feeling toward their patients and supervisees! ."

In a House of Dreams and Glass is an excellent account of a not-so-excellent education; it illustrates the vulnerabilities of a less than perfect teaching system, as well as the strengths that come about from a total immersion into clinical responsibility. It would have been interesting to know a bit more about Klitzman himself, as well as his life outside the hospital, but I recommend his book as a valuable account of one particular kind of training that goes into becoming a psychiatrist.