Compulsive Acts: A Psychiatrist's Tales of Ritual and Obsession

Preface

It is a tempting cliché to say I write because I am a busy psychiatrist with a deep supply of interesting stories. But it would be more original—and more accurate—to say I am a psychiatrist because I have always written or, more precisely, because I have always wanted to write. For as long as I can remember, narratives have swirled around me—it helps to come from a large Mediterranean family whose members have big personalities and intertwined lives. Most of these stories flowed linearly, according to the universal rules of character development and narrative progression. Others, however , defied logic and made little sense, so I looked, by becoming a psychiatrist, for either the tools that could help me connect the dots or the peaceful acceptance that there are behaviors that cannot be explained and stories that are not meant to be understood . Yet, although storytelling has been an important part of my life for a long time, I have not until now written a book for a wide PREFACE ix nonscientific audience. Lack of a suitable protagonist may help explain this. For better or worse, stories, like history, are written about outliers, people at the extremes of the bell-shaped curve. Most of the extraordinary characters I conjured up, however, left me wondering whether their oddity would make them inaccessible to the general reader—that is, until I thought of writing stories loosely based on patients I treated in my psychiatric specialty of obsessive-compulsive disorder (OCD) and behavioral addictions such as kleptomania, gambling, and Internet abuse. These patient-inspired tales possessed the universal, easy-to-relate-to dimension of human suffering. But these stories were also unique in that the rituals and behaviors they depicted were highly unusual and, if I may call them that, colorful. The suffering I saw in these patients, combined with the peculiarity of the symptoms causing it, struck me as a worthy subject for my writing, and convinced me to finally stop thinking of myself as a writer and to actually become one. This choice of subject also allowed me to describe some of the innovative research that our group at Stanford University has conducted over the past few years. Our research into previously little-studied topics like kleptomania and problematic Internet use has been published in peer-reviewed journals and widely covered in the media, often with a dose of sensationalism. Sharing our work with a lay audience and “setting the record straight” about what can and cannot be inferred from it provided me with additional motivation to pursue this subject. But this book is not merely a disjointed collection of research anecdotes and clinical tales. Tying the individual stories together is the overarching theme of my own journey so far in psychiatry and the growth and learning that continue with every patient x / Preface I see, as well as the fascinating dramas unfolding over time among psychiatric clinic staff. Far more than a miscellany of memorable cases, then, this story has a beginning, a middle, and an end. A work inspired by real patients is, however, a fraught affair, and it would be easy for it to end up causing more harm than good. I am referring especially to the possibility of violating a person ’s privacy. One way to avoid such a breach of trust would be to obtain the patient’s informed consent and then freely tell the actual story, using initials in place of the full name. But there are at least two problems with this tactic. First, the patient is never the sole hero of the story. Even if the person agrees to having the story told, what about the long-suffering boyfriend or girlfriend who features so prominently in it, or the abusive parent whose behaviors weigh so heavily on the patient? If these supporting characters can potentially be recognized in the text, should I obtain their consent too? Where should I draw the line? Second, what if a patient has a change of heart about the story being made public as circumstances inevitably change? How would the person handle the fact that what has already been committed to paper cannot be withdrawn? For all these reasons, it seemed to me that a safer approach would be to adhere to the spirit of the story, fictionalizing any identifying details to make the subject and other active players unrecognizable. And this...