by M. J. Cates
“To a wonderful man! A man I loved!”
“Platonically, you insisted.”
“You don’t understand how good Quentin was, how intelligent, how sensitive, how witty, how engaging. How much he cared for me.”
“And what you don’t understand is that none of that matters. He could have been any man. Why would you put yourself in danger by marrying him?”
“Quentin wasn’t dangerous. He was sweet.”
“Yes, yes, you keep saying: sweet, intelligent, thoughtful, loving. What could be more dangerous?”
“I don’t understand you. Love—true love—is not dangerous.”
“But you had no experience of harmless love. You had Josiah Lang—a man who had been the picture of kindness until you uncovered his deception. He ripped from under your feet your entire emotional world. Everything you thought was real, gone. One day you’re a little girl riding her bike, and the next day you’re what?”
“Nothing.”
“He made you feel you were nothing. And then another man comes along promising everything a girl might want in a man. What are the chances she is going to believe him?”
“None.”
“None.” Ganz sat back as if winded. “Indeed.”
They were silent for a time. Usually Dr. Ganz sat looking at her, placid, waiting, but now he tugged at his goatee and pursed his lips and shifted in his chair.
“What?” Imogen said.
“Nothing. I—I’m just struck by something. I think I have been guilty in the past of thinking that it is enough for a psychiatrist to understand why somebody makes the choice they do in a given set of circumstances. But perhaps when we truly understand we see not only why a person makes a particular choice, but how it is impossible for them to make any other.”
8
Luckily, her return to the wards and the needs of her patients kept Imogen from dwelling on her own sorrow for too long.
Georgina Twill was a fifty-five-year-old woman who showed symptoms of dementia that had begun some four years previously, when she became irrationally jealous of her husband. He appeared to be a sweet-tempered man with an honest and open manner. But his daughters, lively young women of eighteen and twenty, began almost to credit the accusations of infidelity—until Georgina also started claiming she was being followed and reported on by “certain employees of Mr. Rockefeller.” She began to hear voices of “evil creatures,” who whispered “disgusting” ideas in her ear. By the time she was brought to the Phipps, she was getting lost in her own home, showed severely impaired short-term memory, and often could not remember the names of common household objects. On the admitting ward she became confused and prone to shrieking fits that disrupted the entire floor.
Imogen’s exhaustive interviews with the husband and daughters ruled out alcohol or drug issues, and there was no history of mental illness in the family. Normal blood pressure seemed to preclude the possibility of a vascular cause, as did the absence of waxing and waning of symptoms. Her deterioration was now steady and swift. Despite Mrs. Twill’s relatively young age, Imogen could see no other diagnosis than senile dementia, with its accompanying dismal prognosis, and Lila Quinn agreed. Mrs. Twill was transferred to a state asylum where she would almost certainly die.
Zen Moldar was a hollow-eyed, hollow-cheeked, thoroughly emaciated forty-five-year-old when he was admitted. Imogen interviewed his aging parents several times, although this was difficult, given their limited English and her lack of Magyar. She learned that they had recently moved to Baltimore from Boston, for work reasons, and had removed Zen from the Worcester State Hospital. At home, he took to wrapping the furniture in wet towels, painting himself different colours, and running screaming down the streets in the middle of the night.
Imogen dug into his history via letter and telephone to Worcester. He had been admitted more than two decades earlier at the age of twenty-three, exhibiting bizarre and uncontrollable behaviour, such as screaming until he would drop from exhaustion. Worcester reported that paraldehyde, bromides, and hydrotherapy could calm him down, but he could not be trusted outside the walls of the asylum and so he languished on a chronic ward. Little wonder that he was disturbed, Imogen thought, having been removed from Worcester, his home for half his life.
She too prescribed paraldehyde, continuous baths, and bromides, but Mr. Moldar was still unable to focus on any occupational therapy. He resisted all attempts at psychotherapy, and spent his days sitting in a chair, smoking and muttering, until one day Imogen saw him staring fixedly at a maintenance man who had come to mop up a spill.
When the maintenance man was finished, Imogen borrowed the mop and pail and brought them over to Mr. Moldar, offering him the mop. She had to wrap his fingers around it, but once she did, his features lit up with the first smile he had displayed since admission. He got to his feet, carried the bucket to a corner, and began mopping. He moved the mop back and forth in slow, thoughtful strokes and squeezed it thoroughly each time he dipped it in the bucket. He got even more pleasure out of polishing, and his ward soon gleamed like no other. Although still delusional and disorganized in his speech, Mr. Moldar responded well to the “cleaning therapy.”
Imogen arranged for his transfer back to Worcester, where he would more than likely live out the rest of his days.
“The family has moved back to Boston,” she informed the staff meeting, “and Worcester promises to let him clean to his heart’s content.”
“Under the circumstances,” Dr. Ganz pointed out, “this can only be counted a happy ending.”
One of the most surprising things Imogen learned about herself during this period was that dealing with depressed, even shattered, people was not in itself depressing. Helping them to find their way to happier thoughts and emotions—even if they were still denied a normal life—could be deeply gratifying.
Mrs. Alma Musky was completely psychotic when admitted. Imogen simply asked her her name and she screamed and rocked and tore at her hair. She had no idea where she was or why she was there. Imogen interviewed the husband and a daughter in her twenties, who revealed that, several weeks previously, the youngest child in the family, a fifteen-year-old boy named Joseph, had unexpectedly died. He had been involved in a high school football game in which he was tackled and hit the ground hard. Unconscious for several hours, he awoke in hospital feeling reasonably well and was released the next morning, but the day after that, when he failed to come downstairs for breakfast, Mrs. Musky went up to wake him and found him dead in his bed.
When the ambulance arrived it took two men to pry her away from the body, and when they were gone she remained in Joseph’s room for the rest of the day and into the night. She could not be persuaded to leave, did not believe her boy was dead, and waited for him to come back. This went on for four days. “She wouldn’t even come to the funeral,” the husband tearfully informed Imogen, “because she didn’t believe he was dead.” Even the autopsy report, which cited cranial hematoma as the cause of death, could not shake her belief that “her perfect angel” would be coming back. She claimed he was sitting in heaven “right beside Jesus” and waiting for just the right moment to be resurrected. All of this was alarming enough, but she began seeing her son in dreams, beckoning her to join him, and now husband and daughter were terrified she was going to kill herself. She kept complaining of undiagnosed heart problems, which she said her son was “sending to her to hurry her along after him.”
After three days of bromides, hot baths, and good sleep, Mrs. Musky calmed down considerably, but still could not accept that her son was not coming back from the dead. She could not even admit that he was dead. Imogen spoke at length with the husband and daughter, and suggested they not try to dissuade Mrs. M. from her delusions, that she was not going to respond to logical argument. “She has no history of psychosis,” Imogen pointed out, “and I truly believe she just needs time—and a protective environment—for the truth to sink in. This kind of reaction to a sudden, unexpected death is no
t uncommon.” In fact she had read about a similar case in Kraepelin. She asked them to bring in items strongly associated with the boy, and simply to sit with Mrs. M. and grieve with her.
After two weeks of this, the husband was in near despair. He had now lost not only his son, but also his loving companion. Imogen assured him she could see improvements. His wife was sleeping again, she was no longer complaining of imminent heart attack, and had not mentioned suicide. She asked him to bring in any letters that Mrs. M. had written her boy, or particularly treasured presents she had given him. The husband returned the next day with a letter she had written to Joseph when he was away at camp. The boy had liked the letter enough to hang on to it and keep it in his dresser drawer.
“Shall I read it to you?” Imogen said to Mrs. Musky at their session the following day. Mrs. Musky nodded, and the tears rolled down her face as Imogen read the words that told the homesick boy, then just eleven, how proud she was of him, of how he was not to worry if others were better at one sport or another than he was, that he was loved and missed so much that it was just not possible for anyone to be more loved.
“Not enough,” Mrs. Musky managed to say through her tears. “Not enough.”
“No, unfortunately no amount of love can save us, or the people we love, from dying, can it. But Joseph knew you loved him. You told him right here in this letter.”
“Oh, I told him all the time. And I always will love him.”
“Yes, and he knew it. He held on to your words, Mrs. M. Even if his life was short, it was full of love, wasn’t it?”
“Yes,” she admitted. “It was, it was.”
“It was,” Imogen said, intentionally echoing the past tense.
She allowed a few minutes’ silence as Mrs. Musky wiped her eyes and caught her breath. Relief was visible in her expression, the way she sat—looking weak, drained, but no longer hunched and rigid.
“It doesn’t have to be today,” Imogen said, “but the cemetery where your son is buried isn’t far from here. I could come with you when you feel ready for a visit.”
That was how the two of them came to be standing, on a crystalline day of sunlight and puffy clouds, at the graveside of Mrs. Musky’s fifteen-year-old son. Mrs. M. knelt beside the grave and stayed silent for many long minutes, but she never again spoke of her boy in the present tense, or of his coming back. She was discharged a few days later to a very relieved husband and daughter.
Dr. Ganz, however, did not appear pleased. “We have here a brief, reactive psychosis in a highly competent woman with no previous history of mental illness. How did you come to see fit to insert yourself into her life like this?”
They were at the staff meeting the day after Mrs. M.’s discharge, and Imogen had been prepared for the question. “I made it plain that this would be a one-time-only event, and that my best place to help her was in the hospital, but the moment was too opportune to miss. Yes, I could have asked her husband to take her to the cemetery, but he had already offered to so many times that she now perceived it as a threat.”
“To visit the cemetery with her, though—it’s a big step outside the doctor–patient relationship.” Ganz spoke firmly but without anger, so Imogen was encouraged to say more.
“I see my role in this case as purely supportive, not analytical, not exploratory. I saw the trip merely as continuing our discussion in another location. I believe it was a breakthrough for her.”
“Luckily,” Ganz said. “But it could have been a major setback, and then where would you be? You would be one more cause of pain in her life, instead of the objective physician.”
“Your little jaunt was not okayed by me,” Lila Quinn put in. “Nor would it have been, had I been consulted.”
“Hardly a jaunt,” Imogen said softly.
Ganz looked around the table. “It may be that from time to time such a bending of protocol may be acceptable. But you must first have the permission of the ward psychiatrist, and if the ward psychiatrist is in doubt, he or she must come to me—is that clear?”
* * *
—
During Imogen’s illness and recovery, Donna had managed to rise even higher in Dr. Ganz’s regard. He now assigned her to look after his private patients when he was away—perhaps the highest mark of esteem he bestowed on anyone. Imogen noticed, with a pang of envy, how the other staff now deferred to Donna, sought her opinion and approval. Even Lila Quinn began to treat her as if she were the presumed second-in-command. Imogen was glad that her friend was doing well, but it was painful to feel that she herself had been set back by an inability to control her own moods.
It was not long, however, before there were faint rumblings of trouble for Donna, the roots of which went to the very nature of psychotherapy and psychoanalysis.
Ganz lectured his interns often on the difference. “It is crucial for you all to understand that these terms are not synonymous,” he would tell them. “Crucial. Psychoanalysis is just one form of psychotherapy, utterly distinct from the others. It is based on Freud’s theories that psychological trouble is caused by the repression of sexual memories or fantasies. Under pressure, the repressed material emerges into consciousness but in a distorted form. Analytic sessions focus on early sexual experiences, and the primary tools are dream analysis and free association. Gradually, very gradually, the patient comes to recognize his own distortions for what they are. I am full of admiration for Sigmund Freud, and you should be too, but underline these words in your notebooks, please: We do not provide psychoanalysis at the Phipps Psychiatric Clinic.”
Donna, it seemed, had neglected to underline. For one day at the staff meeting the ward nurse related, perhaps with some amusement, that one of the younger patients, a nineteen-year-old law student named Hobbes, who suffered from what looked likely to be schizophrenia, had begun using the terms “penis envy” and “Oedipus complex.”
“I thought it peculiar,” the nurse said, “because his mind is so overcharged at the moment that he is not even able to read. He can’t follow a story in the morning paper, for example.”
“Yes,” Dr. Ganz said, “I’ve noticed that myself.” He turned to Donna. “Dr. Artemis, have you been psychoanalyzing this boy?”
“Yes. He seemed such a good candidate, according to his background. Before his trouble he was a big reader, helpful to others, intelligent and thoughtful.”
“Dr. Artemis, perhaps you didn’t hear me, or perhaps you mistook my words for an offhand remark, so let me repeat them now: We do not provide psychoanalysis at the Phipps, do you understand?”
“But the private patients receive—”
Dr. Ganz raised his hand to cut her off. “We do not offer psychoanalysis because even in ideal circumstances, it is a lengthy treatment, usually measured not in months but in years. And it requires an intensity we have not the resources to offer. No one in this clinic can provide four hours of psychoanalysis a week to one patient without depriving other patients of proper care. And even if you were to make some headway, the patient would have to be dismissed before analysis was complete, which means he or she would have to start the whole painful process over again with a different analyst. Most importantly, the likelihood of analysis being of any benefit to a psychotic patient is virtually nil. Such benefit requires judgment, observation, and memory, precisely the faculties that are impaired in the psychotic, when not completely extinguished.”
Dr. Bylsma, whose adjustment from Dutch to American medicine, and to Ganz in particular, was not perfect, raised a pale hand. “Sir, if I may?”
Ganz nodded.
“Ferenczi and Kempf, to mention just two, are quite convinced analysis can help with psychosis.”
“Dr. Ferenczi has many ideas that are not acceptable to Sigmund Freud or to this clinic. I don’t need to go into them here. As for Dr. Kempf, I admire him greatly, but he was fired last year from Indiana for practising psychoanalysis on psychotic patients, and is now experimenting with analysis at St. Elizabeth’s. As of yet, he rep
orts no significant progress. And I note that St. Elizabeth’s routinely houses patients for years, which we do not and cannot do.”
He surveyed the faces around the table. “To go back to this particular patient. Mr. Hobbes is not a private patient. Furthermore, he shows every likelihood of being schizophrenic. While I do not deny that he is capable of flashes of insight, for the most part he seems firmly in the grip of his psychosis. He is in no position to benefit from analysis even in the short term. Just last week, Dr. Lang raised the question as to whether he might not be better served at a state hospital where he could settle in for long-term care. So I repeat: Neither he nor any other public patient is to be engaged in psychoanalysis. By all means listen to him, talk to him, be supportive when you can—ventilative psychotherapy is one of the most powerful treatments we have—but Freudian analysis is not to be attempted. Any effort to do so will be considered insubordination.”
Donna pursed her lips and stared at the table.
Imogen was a little worried about her. When she had emerged from her fog of grief, she’d heard rumours about Donna and a certain psychoanalyst. She had been sighted arm in arm with him at the theatre and in Patterson Park. Imogen resolved to ask her about it and did so the following afternoon when they were sitting across from each other in a tea shop.
“There is no affair,” Donna sniffed. “He is my analyst, and beyond that, he is my friend and colleague. But we are not lovers.”
Imogen knew Donna to be honest—sometimes brutally so—but she was far from sure her friend was telling the truth now.
“Is he the ‘naval person’ Ruth Fein saw you with last week?”
“Oh, he’s thoroughly eccentric—extremely British. He quit the Royal Navy years ago, but he insists on wearing that damn uniform everywhere. His parents were in the Foreign Service, so he grew up in India, Malaysia, Hong Kong—all over the map—and moved over here ten years ago.”