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Book Reviews: Letters to Two Boston Mystery Writers   |    
Shutter Island ? Shrink Rap
Jeffrey L. Geller, M.D., M.P.H.
Psychiatric Services 2003; doi: 10.1176/appi.ps.54.12.1653
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by Dennis Lehane; New York, William Morrow, 2003, 323 pages, $25.95 • by Robert B. Parker; New York, G. P. Putnam's Sons, 2002, 289 pages, $24.95

Dear Dennis Lehane:

Your latest novel, Shutter Island, is a gripping tale that draws the reader in for a sucker punch much like Mohammed Ali's rope-a-dope. The plot has as many twists and turns, flips and flops, as a highly skilled break-dancer on an urban street corner. I couldn't put the book down and read it cover to cover on one long airplane trip. For entertainment, Shutter Island is highly recommended to all readers. Nonetheless, in certain ways, Shutter Island concerns me as a psychiatrist.

Mr. Lehane, you place Ashecliffe Hospital, a maximum-security forensic psychiatric hospital on Shutter Island in Boston Harbor, under some combination of federal and state jurisdiction (there is no such thing). This fictitious island is well placed among the actual islands and landscape of Boston Harbor, and in your acknowledgments you reference All About the Boston Harbor Islands, by Emily and David Kales (1), as having been most helpful to you in writing this novel. I have some awareness of the Boston Harbor islands and environs, and it appears you did a very commendable job. Your descriptions of Ashecliffe Hospital, a forensic facility created by the reuse of prisons and forts from past eras, both is well done and has historical precedent in other locations in the United States.

The plot you create is actually a variant of a technique used in colonial America and referred to as "pious fraud." You blow it up in Hollywood style, bringing it beyond the limits of exaggeration. But it works, and it's fun. So far, so good. It is in your descriptions of psychiatric patients, your use of the history of American psychiatry, and your presentation of psychopharmacologic data where you fall short. The psychopathology of the main character—psychotic denial, fixed delusions, visual illusions, Korsakoff-like symptoms, and some presentations that actually lack psychiatric description and that appear unrelated to how any patient might act—is a fair literary device. No harm done here. The historic errors are generally minor—for example, no patient in the period during which the novel is set would have gone to the "Shattuck" as did your main character; the discussion of serotonin imbalance is considerably out of historic context; and the time at which you have chlorpromazine being used is off by a couple years. Again, no harm done.

The descriptions of the effects and, more important, the effects of withdrawal from psychotropic medication, particularly chlorpromazine, are at best perverse exaggerations. Here, harm is done. Persons who would benefit from the psychiatric pharmacopoeia could see your treatment of psychiatric medications as a verification of all their fears. Harm done. It's both noteworthy and confusing to me why the two texts you choose to acknowledge as "indispensable in writing this novel" are Alex Beam's Gracefully Insane (2) and Robert Whitaker's Mad in America (3). Both are written by Boston-based columnists and writers. I've read both and found them to be interesting and informative. But why no consultation with a psychiatrist, particularly a psychopharmacologist? Why depend on these two sources alone? Without much trouble, you could have had significantly better informed psychopharmacology in your novel without hurting the plot.

Ashecliffe Hospital is the place for care and treatment of the "most dangerous patients in the U.S.A." Of course, there is no such facility in the United States, because there is no capacity—and nor is there any evidence that there should be a capacity—to aggregate such patients. Even so, you could have done a much better job than you did when you chose to present a series of these patients. How dangerous can a patient be who perseverates a couple of sentences and never does more or less? Harm done.

Although you give an indication in the prologue of the period in which the events take place, and you hint throughout the novel as to the period, the reader must pay very close attention to stay reminded that the events took place half a century ago. I fear that all too many readers will lose track of this fact and believe that "partial lobotomies," "spa treatments," "shock therapy" (as you describe it), and "psychosurgery" are all treatments of recent, if not contemporary, use. Harm done.

Perhaps it is unfair of me to hold you, the author, accountable for the interpretations of the less than careful or less than responsible reader. This would be a criticism well taken. However, you are responsible for much that is misleading or simply incorrect and that could have been remedied without any harm to the gripping tale you have written.

I understand that Shutter Island is being developed as a major motion picture by Columbia Pictures. Perhaps in the movie version, the harmful errors of the novel can be corrected. Certainly, the movie could be on one hand a gripping tale and a commercial success and on the other hand could destigmatize rather than stigmatize psychiatric patients and the treatments they receive.

Dear Robert B. Parker:

Being familiar with your Spenser novels, I was looking forward to my first foray into your Sunny Randall novels. Given that this is but your third outing in this series, I figured I wasn't too far behind. Your fans of Spenser and his cohorts may be disappointed that this novel does not feature that detective. But they will be even more disappointed when they discover that this Sunny Randall novel is little more than a puff piece with large font and wide margins aimed at turning a short story or novella into a book-length product that can be sold for $25. Neither the writing nor the plot is anywhere near your zenith and could even be said to muddle around your nadir.

Be that as it may, of interest to me in picking up the book was the fact that psychiatry and at least one psychiatrist were central to the work, hence the title, Shrink Rap. I was aware of the way you treated psychologist Susan Silverman in the Spenser novels. Silverman is Spenser's love interest and provides him with sensitive, thoughtful insights and assessments that, despite his stubborn counterdependent traits, he generally considers seriously. He often acts on the knowledge that Silverman provides.

To my surprise, neither social workers nor psychiatrists fare anywhere near as well in Shrink Rap. For reasons you the author may or not be aware of, you treat social workers as trivial items basically to be discarded. The one social worker who appears in the book is a friend of the main character, Sunny Randall, who herself is a divorced woman in her mid-thirties who is living with her dog, Rosie. The social worker, Julie—who apparently doesn't warrant a last name—is also divorced. She, however, has children who live with her ex-husband, while she lives in a one-bedroom condominium in Cambridge and walks to her office near Harvard Square to "do psychological counseling." The first time she appears in the novel, she puts herself down, saying, "I'm an MSW. Psychiatrists don't mingle with me." The second time Julie appears in the book, Sunny tells her "You're only an MSW." The significance of the fact that the social worker's only two appearances occur in restaurants, one called Cuchi Cuchi and the other called Biba, and that on both occasions she and Sunny are drinking, is beyond my comprehension. Perhaps, Mr. Parker, you could enlighten me.

Two psychiatrists appear in this book. One, Max Copeland, aids Sunny Randall as a consultant, and the other, John Melvin, is the villain. Rarely has there been a more villainous psychiatrist. Dr. Copeland first, however. Max Copeland is a well-informed, considerate, helpful consultant. He is perhaps a little too well-informed—he seems to be an expert in much of medicine far beyond psychiatry, such as toxicology. Even this character couldn't be portrayed as simply a straight-up guy, because apparently you couldn't resist having him regularly play head games with his consultee, blurring the role for both of them into that of therapist and patient.

John Melvin is a psychiatrist in private practice in Chestnut Hill. His clients are almost exclusively women. For Dr. Melvin to take them on as patients, the women have to be attractive. He is also on the faculty of Taft Medical School (a cute substitute for Tufts). He is the former husband of author Melanie Joan Hall, whom Sunny Randall is hired to protect. She needs protection because evil Dr. Melvin is stalking her. Dr. Melvin and Melanie Joan met when Dr. Melvin was Melanie Joan's psychiatrist. Their relationship progressed first to one of lovers and they then became husband and wife.

Through the action of the novel and through the recounting of past events by Melanie Joan, we learn of Dr. Melvin's true practice. Dr. Melvin, a misogynist of the worst order, has a routine that he apparently has used with many women: sedating them, paralyzing them, and having sexual intercourse with them. In a plot device that could easily have been taken right from the pages of You Must Be Dreaming (4), by Barbara Noel, the fictional Dr. John Melvin, like the real-life character, Jules Masserman (5), has no good explanation for his actions.

As heinous as this sounds, Melvin goes on to eclipse what Masserman is accused of, because Melvin brings in two of his wealthy friends to join him in raping the patients. Dr. Copeland's explanation for this is the acting out of some homoerotic fantasy.

The novel has a love interest, threatened violence, and a host of other minor diversions. None of these add up to very much. Sprinkled throughout the novel are sometimes accurate and sometimes inaccurate names, places, and directions in the greater Boston area. Also spread throughout are occasionally inaccurate facts about psychiatry. It is not true that sexual intercourse between patient and treating psychiatrist "happens a lot," unless a percentage of less than 10 percent of psychiatrists who have ever done so (6) can be considered a lot. Nor is it true, as an emergency department physician tells Sunny Randall, that most people who commit suicide leave notes (7).

Finally, as if all this isn't enough, Dr. Melvin may well have committed murder and is caught by a private investigator, Sunny Randall, while she poses as a patient. Randall is rescued just in time to avoid being raped by Melvin and his two friends. Mr. Parker, what were you thinking? Or were you thinking? I can only hope that Shrink Rap is not the first Robert B. Parker mystery that anyone reads, for they will never read another, and that would be unfortunate. They would miss some of your fine outings in the Spenser series.

Dr. Geller is professor of psychiatry and director of public-sector psychiatry at the University of Massachusetts Medical School in Worcester.

Kales E, Kales D: All About the Boston Harbor Islands. Bourne, Mass, Hewitts Cove, 1993
Beam A: Gracefully Insane. New York, PublicAffairs, 2001
Whitaker R: Mad in America. New York, Perseus, 2001
Noel B: You Must Be Dreaming. New York, Poseidon, 1992
Masserman J: Sexual Accusations and Social Turmoil. Oakland, Calif, Reagent, 1994
Gabbard GO, Nadelson C: Professional boundaries in the physician-patient relationship. JAMA 273:1445—1449,  1995
Ho TP, Yip PSF, Chiu CWF, et al: Suicide notes: what do they tell us? Acta Psychiatrica Scandinavica 98:467—473,  1998


Kales E, Kales D: All About the Boston Harbor Islands. Bourne, Mass, Hewitts Cove, 1993
Beam A: Gracefully Insane. New York, PublicAffairs, 2001
Whitaker R: Mad in America. New York, Perseus, 2001
Noel B: You Must Be Dreaming. New York, Poseidon, 1992
Masserman J: Sexual Accusations and Social Turmoil. Oakland, Calif, Reagent, 1994
Gabbard GO, Nadelson C: Professional boundaries in the physician-patient relationship. JAMA 273:1445—1449,  1995
Ho TP, Yip PSF, Chiu CWF, et al: Suicide notes: what do they tell us? Acta Psychiatrica Scandinavica 98:467—473,  1998

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