The Couch, the Clinic, and the Scanner: Stories from Three Revolutionary Eras of the Mind

by David Hellerstein

Winner, 2023 Choice Outstanding Academic Title

Over the past several decades, psychiatry has undergone radical changes. After its midcentury heyday, psychoanalysis gave way to a worldview guided by the Diagnostic and Statistical Manual, which precisely defined mental disorders and their treatments; more recently, this too has been displaced by a model inspired by neuroscience. Each of these three dominant models overturned the previous era’s assumptions, methods, treatment options, and goals. Each has its own definitions of health and disease, its own concepts of the mind. And each has offered clinicians and patients new possibilities as well as pitfalls.

The Couch, the Clinic, and the Scanner is an insightful first-person account of psychiatry’s evolution. David Hellerstein—a psychiatrist who has practiced in New York City since the early 1980s, working with patients, doing research, and helping run clinics and hospitals—provides a window into how the profession has transformed. In vivid stories and essays, he explores the lived experience of psychiatric work and the daunting challenges of healing the mind amid ever-changing theoretical models. Recounting his intellectual, clinical, and personal adventures, Hellerstein finds unexpected poetry in hallways and waiting rooms; encounters with patients who are by turns baffling, frustrating, and inspiring; and the advances of science. Drawing on narrative-medicine approaches, The Couch, the Clinic, and the Scanner offers a perceptive and eloquent portrayal of the practice of psychiatry as it has struggled to define and redefine itself.

Genres: History, Psychology

265 pages, Kindle Edition

Published May 9, 2023

Reviews

[Holly · Rating 4 out of 5]

The Couch, the Clinic and the Scanner provides a compelling account of how psychiatry has changed as experienced by a practitioner (from1980 to the present). It is a fascinating inside and candid look at Dr. Hellerstein’s life, his patients and his research. What makes The Couch, the Clinic and the Scanner especially captivating is that Hellerstein’s career and experiences mirrors the evolving science of psychiatry. The Couch, the Clinic and the Scanner is not at all technical or clinical. In fact, it reads more like a memoir, which it sort of is, while also reporting on the recent history of psychiatry.

The title aptly captures the three stages of psychiatry’s recent evolution and Dr. Hellerstein’s career. The Couch refers to the “talking cure” advanced by Freud. Hellerstein discusses his early training and his experiences applying psychoanalysis.

When the DSM-III was released in 1980, psychiatry went through a major transformation. This third version of the DSM was so revolutionary because it replaced psychodynamic information with explicit diagnostic criteria and utilized a neutral approach with respect to the causation of the illness. The Clinic stage brought about new treatments including psychotherapies to target particular diagnoses.

The third and current stage consists of brain imaging (MRI and Petscans) and alternative therapies that are more personalized treatment of the individual. Neuro-imaging techniques are becoming useful diagnostic tools but the research here is ongoing. This approach considers that mental illness causes damage to the brain if untreated and that proper treatment may include a healing of sorts. Treatments include supplements, yoga, mindfulness, exercise, and psychedelics.

Dr. Hellerstein, besides sharing his experiences and his patients, also asks thoughtful questions throughout his book, such as Has psychiatry improved through these three eras? Does each one build on the former? Are patient treatments more successful?

Anyone interested in psychology or psychiatry would like this book and find it to be very interesting and informative. Due to my own background in psychology, I found Dr. Hellerstein’s account to be an important record of how both diagnoses and treatments have changed over the years and where we are headed. I hope that in a few years or so, Dr. Hellerstein will inform us of the progress made in the Age of the Scanner.

Thank you to Columbia University Press and NetGalley for an advanced reader copy in exchange for my honest opinion.

[Dea · Rating 5 out of 5]

The Couch, the Clinic, and the Scanner
Pub Date: 09 May 2023

This book is a wild, introspective ride, and not anything I would have expected given the docile cover. I expected a tour through the history of psychiatry, but I received worlds more. I got the tour of an amazing man's career, starting from his training and early attempts at psychoanalysis, the emergence of the DSM, to the heigh of big pharma pushing pills on everyone for everything, to the age of brain imaging, and finally to the him starting his own psilocybin (aka, magic mushrooms) center at Columbia University!

All along the way, there are incredible personal stories about his career and personal life, client stories (some sad, some lighthearted and entertaining-- perfect balance of both), and a thought-out connection of how one same case could be interpreted and treated across all three different ages of psychiatry.

Above all, David Hellerstein's rollercoaster career path is inspiring and relatable to anyone who ended up in a job they never expected but one they couldn't imagine their lives without. He trained as a psychoanalyst at Payne Whitney (the center famous for having clients like Marilyn Monroe!), realized that wasn't a great fit for his personality or abilities, decided to be a clinician at a city hospital, succeeded at that path to the point of gettin a leadership position, before transitioning into academic research, something he vowed to never do.

Regardless of this nonlinear career trajectory, Hellerstein still made a huge impact on psychiatric research, late starts aside. He is a well-established researcher with over 100 publications, 4,000+ citations, and collaborates with field giants like Brad Peterson.

Throughout the book, Hellerstein is stunningly open, honest, and blunt about his life, career, and the past, present, and future of the field of psychiatry. This book felt like having a really long lunch chat with a senior professor rather than reading a history nonfiction book. 10/10, highly recommend.

Huge thank you to NetGalley and Columbia University Press for an advanced reader's copy in exchange for an honest review.

[Rowena Hoseason · Rating 4 out of 5]

This isn’t one of those medical memoirs which tells its tale solely through real-life case histories. Sure, the author uses accounts of his patients’ progress (or lack thereof…) to illustrate his themes, but much more is told from his professional perspective as a lifelong practitioner in American psychological / psychiatric medicine.

We follow David Hellerstein through the three defining phases of his career: the first struggling to apply the drawn-out Freudian talking cure, the second using the DSM handbook for diagnosis and practical pharmaceutical treatment, and his recent years using modern technology to investigate the biological origins of mental disorder.
The second two stages are much more interesting than the early part which – to be blunt – was am effort to wade through. This inevitably reflects the career of almost any medical practitioner, gritting through a ghastly decade of stressed-out insecurity and feelings of inadequacy about competency. If anything, this part is about how not to heal the mind…
However, the subsequent sections are far more engaging and rewarding, detailing genuine progress in helping patients – and, on occasion, lifting the lid on where things go wrong. The section on off-label prescribing offers huge insights. The case history of the family where depression was ‘infectious’ was extremely thought-provoking, as was the sad case where a couple were ‘cured’… only to find that their illness was all that united them.
The language may be a little technical for some (not sure how many people actually understand the process of epigenetic modification through methylation or acetylation, for instance). Even if you don’t recognise all the medical terminology there is plenty here to provide insight into modern methods of understanding and possibly treating depression, anxiety and a whole host of cognitive disorders.

So it’s worth slogging through the front end to get to the good stuff. Although you could actually skip most of ‘the couch’ segment and not miss much!
8/10

[Chelsea Littleton-Harper · Rating 4 out of 5]

In "The Couch, the Clinic, and the Scanner," psychiatrist David Hellerstein takes readers on a captivating journey through the evolution of psychiatry over the past several decades. With insightful essays and vivid anecdotes drawn from his own experiences practicing in New York City, Hellerstein offers a deeply personal and illuminating exploration of the profession's transformation.

Hellerstein's narrative is both enlightening and engaging as he navigates the shifting landscapes of psychiatric theory and practice. From the heyday of psychoanalysis to the rise of the Diagnostic and Statistical Manual and the current dominance of a neuroscience-inspired model, he skillfully traces the evolution of psychiatric paradigms and their impact on clinicians and patients alike.

One of the book's strengths lies in Hellerstein's ability to blend personal reflection with professional insight. Through his encounters with patients, colleagues, and scientific advancements, he paints a rich and nuanced portrait of the challenges and rewards of working in the field of psychiatry. His prose is evocative and eloquent, offering readers a glimpse into the often-hidden world of psychiatric practice.

What sets "The Couch, the Clinic, and the Scanner" apart is its emphasis on narrative medicine—an approach that prioritises the power of storytelling in understanding illness and healing. Hellerstein skilfully weaves together clinical observations, scientific discoveries, and personal anecdotes to create a compelling narrative that resonates with both professionals and lay readers.

[Andrea · Rating 5 out of 5]

The Couch, the Clinic, and the Scanner is a very good description of the evolution of psychiatry from the not too recent past to present.

With hearing Hellerstein talking about his initial training and his experiences, then him having to adapt to a change in how psychiatry is practiced multiple times, I am left understanding why many people have left the field and why many people refuse to go into the field. I think Hellerstein is trying to point this out.

He starts with discussing his initial training which ran parallel to psychoanalysis to what is now neuropsychiatry. He goes into fantastic description as to what each stage has been like, what he has been able to take from one stage and apply to another, and where everything has coalesced and left him now. It shows that he is, and psychiatrists today in general, must be adaptable.

I need to add something else - one thing Hellerstein points out without actually fully coming out and say it - psychiatrists are human too, and like other doctors, they want to be there for their patients and give them the best possible care. However, at present best possible care in psychiatry is totally and has been totally different than the rest of medicine.

Personally, I'm glad to hear a psychiatrist's actual story. To people outside of the mental health system, I think this will give them some perspective as to what really goes on in psychiatry whereas to most people, well, they're clueless.

[J Earl · Rating 5 out of 5]

The Couch, the Clinic, and the Scanner by David Hellerstein is a fascinating look at how psychiatric care has changed over the past half century or so, from the dominance of psychotherapy to the current combination of psychiatry and neuroscience. What makes this a compelling read is the memoirish aspect, which makes it both informative and personal.

The changes in care during Hellerstein's career are explained and illustrated with people he has worked with. But it isn't just their journeys that make this so interesting. He is open about his own journey as well, both as a person (an ongoing requirement in psychotherapy) and as a professional. The ways he has modified his practice is an ideal way to make how these changes in understanding and treating mental health conditions impact the patient.

I would definitely recommend this to those with an interest in psychology and mental health, but I would also highly recommend this to readers who enjoy memoirs that focus on a person's professional life as a way of understanding the person.

Reviewed from a copy made available by the publisher via NetGalley.

[Nada Glick · Rating 5 out of 5]

I loved this book! Psychiatrist David Hellerstein not only details what he considers the three historic approaches to, and the history of psychiatry, but candidly and sometime humorously relates his own experience as a psychiatrist in training and his early years of practice in trying to become proficient/effective in each approach. He tells of the various settings in which he has practiced, and which he most felt competent and fulfilled, and tells many case studies. But most important and engaging to me, is how, through his patients, their responses or lack of responses, they "teach" him how to become a psychiatrist. Whether you are in the mental health profession, or a patient, or someone who enjoys self-searching, sometimes humble, sometimes humorous, life stories, this is a must read.

[Kimberly Barnes · Rating 4 out of 5]

The Couch, the Clinic, and the Scanner is a psychiatrist’s account of how the practice of psychiatry has changed over time. The approach to treatment of mental illness has radically changed throughout the years. As explained by Dr. Hellerstein, there is a new understanding that mental illness is now related to psychology AND biology. Dr. Hellerstein uses his own experiences as well as, stories about patients to provide insight into his work in hospitals, clinics, and research. This book details Dr. Hellerstein’s experiences of trying to help patients, while dealing with overworked hospital staff and doctors, and navigating medical bureaucracy. Thank you the publisher and NetGalley for the advance review copy in exchange for my honest review.

[John Markowitz · Rating 5 out of 5]

The Couch, The Clinic, and the Scanner describes three hospitals, three phases of the author Dr. Hellerstein’s life and psychiatric career, and three eras of psychiatry. Hellerstein’s career path crossed the heyday of psychoanalysis, the rise of the DSM and clinical diagnosis, and now inhabits the advent of neuroscience. Few writers have his skill in decoding medical jargon for the public and communicating the experience of interacting with patients who suffer from psychiatric disorders. These sequential essays often read as moving short stories, acknowledging the dilemmas and uncertainties that psychiatrists in all three eras have had to face. Mental health professionals, patients, and the intellectually curious will enjoy and learn from this book.

[Rachael · Rating 4 out of 5]

Thanks to NetGalley and the publisher for the e-ARC. I really enjoyed this engaging journey through both the author's career as a psychiatrist, but also how the field of psychiatry has changed and evolved over the decades. A great read for those interested in mental health and really nicely written.

[Bonni · Rating 3 out of 5]

This is an interesting look at the progression of the mental health field from the 1970s through today. I like the combination of memoir, case studies, and scientific research. One big missing piece is metabolic research, but perhaps Dr. Hellerstein’s research is more focused on psychedelics right now. The formatting of the galley ebook distracted from the content somewhat, but I assume all issues will be resolved in final published copies