Stepping Into The River: Four Lives In Therapy Across Time

(under consideration)

The book tells the story of four patients’ lives as seen through the lens of psychiatric treatment, provided by one psychiatrist. The patients are part of a larger data base where we have detailed 30 year prospective follow up. The book shows how psychiatry has acquired many tools to provide more targeted and integrated treatment which has an excellent chance of leading to positive outcomes. Psychopharmacology, psychotherapy and socio-therapy are shown to have their important part to play in reconstituting patients to lead healthy and productive lives despite sometimes overwhelming challenges.

Two women and two men begin their journey through adolescence with major struggles. The worlds of poverty and privilege pose their own challenges which these patients have to master. The book accompanies them through their adolescence and young adulthood and ends at them reaching middle age. Twelve interlinked stories, three per patient, show their progress, which extends from 15 to 35 years. Treatment is not necessarily ongoing during these many years, but is reactivated when the patients struggle anew while crossing into a new stage of development.

Although these stories are about specific individuals, each patient represents a type and cluster of problems familiar to most clinicians and the educated and affected lay audience. As they struggle with problems of eating, alcohol, drugs, attention, learning, impulse control, aggression, depression and anxiety, they deploy their unique set of strengths to recover with the help of the psychiatrist, who also serves as a deep fund of knowledge across time. The reader has  access to the psychiatrist’s thinking, conflicts and uncertainties, as he is repeatedly put in situations where he has to make life and death decisions, with incomplete information while  under great time pressure.

Descending Into The Abyss: Bringing Medicine to Crime

Accepted By: Sterling Lord Literistic, New York City, 2017, Contact Agent: John Maas


For Truman Capote. He stared, forgot and paid the price.

Descending Into The Abyss: Bringing Medicine to Crime is a book about young people who commit murder and other violent crimes. It is also a book about the ways I’ve used as a psychiatrist to assess and treat incarcerated juveniles who have committed these crimes. My task always begins after the fact.  The crime has been committed.  The young person has been adjudicated and is in an incarcerative setting. Efforts at the prevention of crime have failed miserably for these youths. My task is to restore them to a state wherein they can be returned to the community. My involvement with these kids over thirty years has led me to discover ways of making sense of the atrocities they’ve committed by bringing the tools of modern psychiatric medicine and a good deal of intelligent common sense to bear on their cases.   My job is to help them. Treatment, healing and restoration is their only hope. It is this knowledge that Descending Into The Abyss: Bringing Medicine to Crime will bring to a general reading audience.

There is a further purpose to this book  -- a very important purpose – that is well beyond the simple imparting of information and the gathering of knowledge.  My involvement with delinquent youth who have killed has brought about a watershed catharsis in my own thinking about the very nature of children as well as the very nature and meaning of murder.  I feel that we need a truly compelling new attitude in our societal policy for such youth and -- most particularly – in our treatment of them.  As a society, we do not understand this phenomenon of youth who kill and, in our ignorance, we are stymied by it, seek to brush it under the rug, condemn it thoughtlessly as sheer moral evil, or attempt to treat these children as if they were adults. We ignore it, sensationalize it or just bemoan its existence.

We’ve been thinking about this problem in the wrong way. Currently we believe that because young men and women commit severe crimes, they are somehow just explosively unusual, just unexplainable.  We put them in jail and ponder the notion that perhaps the times themselves are therefore unexplainable. We think that simple incarceration is a means to a cure.

But the fact of the matter is that incarceration alone without treatment is unlikely to change much. Recidivism rates of incarcerated but psychiatrically untreated youth are extremely high. At best, incarceration without treatment is a lengthy time out, in which the young people may reflect on their lives and their futures.  That’s unlikely, though, if they don’t have help.  They need much more from us.  They need to be able to think about and understand their crimes, and they need qualified help to do this.  They need new tools to navigate life’s treacherous waters, and guidance on how to use those tools. They need to be taught, treated and made ready for return. In the current political atmosphere, much stock is placed in  dealing with youths who kill by trying them as adults and  meting out severe punishments, even death sentences. This path is not likely to succeed either.  We must approach the issue in a much more comprehensive way, one that is realistic and compassionate.   

This is not simply an altruistic suggestion on my part.  There is a very important set of facts that accompany my reasoning. Ultimately, most of these youngsters will return to their communities – or other communities – an average of two and a half years after they have committed their crimes. They committed their crimes as juveniles and were sentenced as juveniles.  So they will shortly be released. A youth like this could be your neighbor, your daughter’s boyfriend, your son’s babysitter. Without treatment, he could be back in the community, next door to you, still ignorant, still angry and vindictive, still seeking, perhaps violently, to right all the wrongs that life has dealt him.  On the other hand, if he is well-treated during those two and a half years, restored to mental health and put on a positive developmental trajectory, he’ll have a much better chance of finding his way back to normal society.

Treatment , education and confinement is the formula I advocate. Many of these youngsters, while still on the streets, have failed previous efforts at treatment. The world has been too much for them.  They’ve been bombarded by elements they cannot understand because of social, psychological and psychiatric limitations But now, their confinement  -- still as youths  -- offers a completely new opportunity to get them developing on a more healthy path before they turn too old to be influenced at all by  interventions. So, interestingly, for these incarcerated kids there is a window of opportunity between mid-adolescence and young adulthood through which we can reach many before they embark on a lifetime career of violent crime. Many of them attempt to exit from their antisocial trajectories, realizing that those bring a dangerous and uncertain future. Many of those trying fail, because their adaptive repertoire in many domains of functioning – interpersonal, academic, vocational, basic medical health habits and avenues to re-create – is so limited  for reasons to do with medical disorders or social disadvantage.

We need effective treatment, treatment that must be brought to the very places that handle these young killers and other delinquents, and we need to do it while they’re there. Funding such efforts will be a case of money well spent. We will spare much suffering and grief. Modern psychiatry has much to offer to our efforts to treat these kinds of crimes more reasonably and effectively. And we should do this, if not for any other reason than that these murderers are not so different from you and me.  In my opinion it is realistic to think that all of us  -- every one of us  -- harbor vulnerabilities and capabilities that in the wrong climate could be activated and magnified, leading to disastrous outcomes.  This interpretation is part of a body of psychiatric knowledge that has developed over the past  fifteen to twenty years that needs to be brought to the attention  of the general public, to help them understand what’s going on with these youths and to advocate proper treatment for them.