In Two Minds

by Gordon Parker

  ‘I wanted to buy an investment property. I told an agent that I had far more money than I actually had, although I semi-believed it at the time. And in fact, that even if I didn’t have all the money, it didn’t matter. That things would all fall into place.’

  ‘Did you sign off on the deal?’

  ‘No.’

  ‘That’s good then. Did you take other risks?’

  Sarah cut in. ‘He apparently bought a skateboard and was careering around the suburb late at nights.’

  ‘Note an increase in your libido?’

  Sarah raised her eyes to the ceiling. She could also answer this question.

  Martin spoke slowly. ‘It got out of control.’ He swallowed dry hubris and said even more slowly, ‘And I became involved with another woman.’

  Marshall hesitated briefly. ‘I don’t need to know the details and I don’t want to embarrass you in front of Sarah…’

  Martin cut across him. ‘It’s not an issue of embarrassment. It’s one of shame. Utter, utter shame. I’ve never had any wish to be with any other woman. And yet, it happened. I met a woman who bewitched me. And I became driven by hedonism and self-indulgence. And now I feel nothing but shame. It’s put our marriage at risk but that’s something that Sarah and I will have to resolve.’

  Sarah sat there impassively although Martin’s detailing of his infidelity caused her to fume. How could she trust him in light of what had happened? Was he now just talking the talk? And talking to her via Marshall? Was he perhaps seeking some justifying explanation from Marshall? Her response was to provide no response other than to lower her eyes and look blankly at Martin.

  Marshall softened his approach. ‘Martin. Sarah. During highs, people do things that are completely against their character. In Patty Duke’s autobiography she observed, When you’re manic, there are no consequences.’ Sarah continued to provide no response. She had expected Marshall to encourage them to make some allowance but this one appeared too pat. Perhaps the two males were buddying up against her?

  Marshall turned back to Martin. ‘Any other risk taking? Driving faster, taking more alcohol or drugs?’

  ‘I drank more alcohol but it didn’t seem to affect me.’

  ‘Yes, during highs people can turn wine into water. And what about psychotic features? I understand you thought you were in communication with your mother.’

  ‘That happened later. I became convinced she was talking to me, giving me advice.’

  ‘Was the voice in your head, or outside?’

  ‘Inside.’

  ‘And you believed what she said. Acted on her voice?’

  ‘Yes.’

  ‘But all these symptoms have settled?’

  ‘Went completely a couple of days ago.’

  ‘And no previous highs – high moods – ever.’

  ‘Never.’

  ‘Did the high impair your work?’

  ‘Not in the early stages. I was actually more efficient and even more empathic in my view. Sometimes I could tell what people were feeling even if they didn’t say it. And I kept control of it to some degree by exhausting myself physically.’

  ‘And during all those weeks you didn’t seek medical attention.’

  ‘No. I thought I could work my way through the depression myself and then, when I was in the up mood, I felt on song and had no need for help.’

  ‘So, did you self-medicate?’

  Martin had anticipated the question. He had earlier resolved to deny, less because of any consequences and more because of shame. But now, as he looked at Marshall, he knew that Marshall already knew the answer.

  ‘I started taking a tricyclic.’ Martin noted Sarah pull a face but Marshall remained impassive.

  ‘Which one?’

  ‘Dothiepin. And it worked, almost from the beginning.’

  ‘At what dose?’

  ‘I took it up to a hundred and fifty milligrams reasonably quickly.’

  ‘How quickly?’

  ‘A few days, actually.’

  ‘Did you miss any doses or take more than a hundred and fifty milligrams?’

  ‘I don’t think I missed any nights. Over the last week I think I was taking two hundred and twenty-five milligrams. The day I was admitted to hospital I took a couple more tablets as there was a huge argument and I didn’t want to go back into depression.’

  ‘What dose?’

  ‘Two or three tablets.’

  ‘The twenty-five milligram or the seventy-five milligram tablets?’

  ‘I’m not sure.’

  ‘And after that?’

  ‘I don’t know. Things were a blur from the time of the argument till a day or so ago.’

  Marshall spoke thoughtfully. ‘Presumably when you went from hypomania to full mania.’ He reverted to questioning. ‘And how are you feeling now? Still high at all? Or depressed?’

  ‘Neither really. Pretty flat. Shattered about everything. About where I am. What I’ve done. What the repercussions will be. And physically I’ve been feeling horrible.’

  ‘What symptoms?’

  ‘Shakes, headaches, agitation, some dizziness, lethargy and loose bowels. Although they are all a bit better. I’m told they’re due to the lithium and they should settle.’

  ‘And is there a family history of mood problems or bipolar?’

  ‘My father had severe depression.’

  ‘No one else in the family? Grandparents, uncles, aunts, cousins?’

  ‘I don’t know. It wasn’t talked about.’

  Marshall leant back in his chair. ‘Anything else that could be of relevance?’

  Martin shook his head and locked his hands. It was diagnostic time. His future was going to be shaped by the professor. For Martin the boot had always been on the other foot. It was he who communicated diagnostic and management information to patients. What they had and how it might best be treated. And for those with more gravid conditions, how it might affect their life – even bring it to an end – and how he would seek to help them on the journey. Most of his patients appeared untroubled during such periods, a few asked questions, some might take notes but it was rare for anyone to reveal their inner world at such times. But Martin felt fearful. Would his mood disorder be chronic, would it require heavy medication with multiple side-effects, would he need to be hospitalised again, would he be able to work? And would Sarah walk away from him, unable to accept his behaviour, his infidelity, his betrayal of trust or because of the prognosis to be given by the professor? He lay back, sinking his head into his pillow.

  ‘I’m feeling a bit whacked. Please keep talking. I’m listening.’

  ‘I have no doubt you have had a melancholic depression. There is a family history and you report all the classic features. You also have certainly had a high. As I indicated, hypomanic for a period and then a shift into a psychotic manic phase. But what I’m not sure about is whether you truly have a bipolar condition – be it bipolar one or two – or whether the high was simply caused by the tricyclic – what we call a bipolar three state and not really a bipolar condition at all.’

  Sarah raised her eyebrows when she heard the word caused. Marshall turned to her. ‘All antidepressant drugs can cause what is termed switching, pushing a depressed person into a high, and the tricyclics are fairly potent switching drugs.’ He turned back to Martin who had sat up again. ‘You took a fair whack, Martin. You took the dose up too fast and your manic episode – when you became actively psychotic – was preceded by you taking an extra amount, and from what you say it might have been quite a lot. And then, because you didn’t tell the staff here about the tricyclic and it isn’t tested in our standard drug screen, they didn’t progressively taper it to avoid withdrawal symptoms.’

  Sarah queried Marshall. ‘The staff told me he had come out of the manic state faster than expected. Could that be the reason?’

  ‘It supports it. And most of the side-effects you’ve been reporting are almost certainly tricyclic withdrawal symptoms, especially as t
hey were settling during the time the lithium dose was actually being increased.’

  Sarah looked eagerly at Marshall. ‘So he may not have a bipolar disorder at all?’

  ‘Exactly. He’ll need some judicious management and I guess only time will tell.’

  Martin felt relief but not quite a reprieve. He still had a mood disorder, he had been hospitalised, the police had been involved and the Medical Board would be informed of his psychiatric problems. He looked at Marshall.

  ‘Would you be able to manage me?’

  ‘That’s your call, Martin. You have to stop treating yourself and it wouldn’t be wise to select a psychiatrist who is also your friend. There are several others in the city who are good at managing mood states.’

  ‘No. I’d like to have you.’

  Sarah leant forwards. ‘I’d also be pleased if you could manage Martin.’

  Marshall nodded. ‘That’s fine then. I’ll give Fielding a brief. Essentially, I’ll recommend tapering and ceasing the olanzapine, keeping you on the lithium for the moment and putting you back on the tricyclic at a low dose to settle the withdrawal. If it was simply a bipolar three-type reaction we should be able to slowly reduce all but the antidepressant over time.’

  ‘And if not?’ Martin asked. ‘What if it is bipolar?’

  ‘Then a mood stabiliser. I favour lithium for bipolar one and lamotrigine is generally excellent for bipolar two.’

  ‘He’ll need to take an antidepressant for ever?’ asked Sarah.

  ‘If it’s not a bipolar state then most people with a unipolar melancholic state need an ongoing antidepressant. Once melancholia has emerged – and it generally does as it did here, following a stressor – it tends to come back, even without distinct stressors. That’s why it was long called endogenous. Each person has their own pattern so it might reoccur several times a year for one person and only every decade or so for another. We can get some people off their antidepressants completely but it’s only about ten per cent. Best to view melancholia like type one diabetes or hypertension. We can’t cure it but we can control it with an antidepressant. Whether with a tricyclic or another one is another matter for resolution.’

  Martin spoke softly. ‘When can I get out of here?’

  ‘Perhaps tomorrow, if not Sunday. Fielding will need to be briefed and agree but I don’t see any problem there.’

  ‘And the Medical Board will be informed?’

  ‘It’s mandatory. Non-negotiable. But it doesn’t have to be by the superintendent. You could report yourself. I’d favour that approach as the Board will look more favourably on it. Do it in the next few days and I’ll see you next Tuesday in my rooms. Just a matter of ringing my secretary. But don’t go back to work yet.’

  Martin smiled and stood up to shake Marshall’s hand. ‘I’m extremely grateful, Saxon.’ Sentiments quickly echoed by Sarah.

  ‘Yes, Saxon, thank you so much. It’s such a relief.’

  Marshall nodded. ‘My pleasure.’ And left the room.

  Martin sat back up, slowly shaking his head. ‘I almost feel I’ve got a get out of jail card.’

  Sarah sat opposite him on the bed, readily able to resist giving him a reassuring hug. ‘Certainly a get out of a mental hospital card. He was pretty impressive, wasn’t he?’

  ‘Efficient indeed. A bit mechanical though. But he warmed on me.’

  ‘What would you prefer? Skill or care from your doctor?’

  ‘Both actually.’

  Sarah nodded. ‘It’s great news that you can come home soon…’ Her voice trailed off. Both knew what she was leaving unspoken. It was Martin who broached the painful topic.

  ‘Sar, I know you are going to have a lot of trouble trusting me again. For me to have had an affair is an absolute betrayal. I can’t really explain how I broke the values I thought I possessed. I’m not sure if you –’

  Sarah cut across him. ‘Well I’m certainly willing for you to come home. I suspect we’ll walk around each other for a while. I don’t know whether trust can be restored but I’m prepared to give it a try. But what if you go manic and start chasing some Jezebel again?’

  Martin shook his head and rose to give her a hug. Sarah put up a hand to block him. ‘And that was not the only duplicity. You started taking those antidepressant tablets without telling me. You weren’t in a manic state then. You can’t excuse everything you did on the basis of mania. We used to pride ourselves on being open to each other. About everything. I just don’t get it. Why did you self-medicate?’ The question was tinged with worry but ended with an accusatory inflection.

  Martin dropped his head slightly. ‘You’re right. I did it with full awareness. I didn’t want to worry you.’

  Sarah shook her head. ‘How do they describe a doctor who treats himself?’

  Martin responded with a wry grimace. ‘“Fool” is the usual term.’

  ‘How would you respond to one of your patients who was self-medicating and not telling you?’

  Martin judged it best to regard the question as rhetorical. He felt a need to plead. ‘Sar, do you believe in absolution?’

  ‘No, I don’t actually. Too easy to have one’s acts of guilt struck off with a benediction or a gesture. Or bought off with some expensive present, perhaps a diamond necklace or an anklet.’

  Martin sighed. The diamond anklet that he’d bought and never given to Bella. Sarah had found it, presumably when she had gone through his car. She must have thought it was a present for her to welcome her home. No, worse. She would know that he would never have bought her an anklet. It just wasn’t her. The anklet had been expensive, so expensive as to not be him, but it was going to cost him a lot. He spread his hands.

  Sarah continued as if unaware of his spreading chagrin and shame. ‘But I do believe in redemption. It involves a process. And, for us to be reconciled, I need to fully believe that we have the elements – the positive things – that seemed to define our relationship is back in place again. You need to restore my belief.’

  ‘I owe you so much, Sar.’

  ‘Well just don’t run up any more debts. As I said, if you ever make contact with that woman again, our relationship is over. That’s absolutely non-negotiable.’ Sarah stood up, put her hand on Martin’s shoulder but chose not to accept his offered hug, and slipped out of his room.

  Martin lay on his bed for an hour, processing the interview and Sarah’s responses to him. She could not have been more generous. Reconciliation was achievable and atonement would be his goal.

  A nurse poked her head through the door to inform him that Dr Fielding had agreed he could be discharged the next morning, news that immensely cheered Martin. He needed to clear his head, walk in the sun and look up at the sky. As he went to the airing court his side-effects felt relatively slight and he walked with a lighter step. He saw Clarissa on the bench and joined her. She gave him a welcoming smile.

  ‘You’ve been in your room?’

  ‘Yes.’

  ‘Sleeping or escaping?’

  ‘More processing things.’

  ‘Productive?’

  ‘Yes, at many levels. Thanks indeed for asking. You are very generous.’

  ‘I think I can pick a fellow traveller, Martin. I appreciated you listening to me earlier. I couldn’t tell my private psychiatrist. He would keep interrupting with interpretations. Sometimes I just want someone to listen. That can be more therapeutic. Whoops. There’s a nurse heading towards us.’

  ‘Have the nurses spotted you as an imposter?’

  ‘They’re suspicious. It’s actually hard work to play sane here.’

  The nurse called out as she drew closer. ‘Martin, you have a visitor. I’ve sat her down in your room.’

  Martin wondered why Sarah had returned. He excused himself from Clarissa and went to his room. On opening the door he saw Bella. She was sitting on the room’s single chair, rigid as if in a straightjacket of controlled authority. Martin’s first instinct was to leave the room and call for a nurs
e.

  Bella spoke in a calm but steely voice. Her charcoal eyes, however, were raging. Martin was furious and amazed that she had entered his territory, the sanctuary of his bedroom in this asylum with all its inviolable connotations. Like Shakespeare’s description of the meeting between the King and Camillo, they seemed almost, with staring on one another, to tear the cases of their eyes.

  ‘Don’t be alarmed, Martin, I won’t bite you.’ A wave of her hand indicated that she thought he might wish to sit on his bed. She was dressed in a businesswoman’s suit, predictably one with long sleeves. She still struck him as beautiful, but now in a formal way only, lacking the aesthetic beauty that had taken him to a state of ecstasy at their first meeting. He felt neither attraction nor empathy, only cold anger, both protective and intrinsic.

  She spoke slowly and unemotionally. ‘You don’t know how much you disappointed me, Martin. I thought you cared for me, that you would help me to find a career and that we had a future together. I am, incidentally, a very rich woman.’

  ‘I’ve been unwell, as you can clearly see from where I am now.’

  Bella responded icily. ‘Write to Miss Lonelyhearts. Don’t whinge to me. I think you’re a sociopath. Pretending to be the kind doctor but operating to your own agenda. Use people and then abandon them. And when you saw that you couldn’t just walk out on me without repercussions, you bloody well sought to protect yourself. You chose not to stop my bleeding. You protected your own reputation without any consideration of me by getting your colleague to come and give medical assistance and then you contrived madness to get into hospital to exonerate yourself from a whole set of repercussions.’

  Martin knew that Bella’s paranoid state would be unresponsive to any argument. He needed to abort a situation that could further escalate. ‘Bella, I’m going to get a nurse and have you escorted from the ward.’ He moved towards the door.

  ‘Don’t bother. I’m leaving.’ As Bella brushed past him, he felt her stiff body. She preceded him up the corridor, smiling at patients as she passed them and, with an engaging smile, asked a nurse to buzz her out of the ward.