by The Naked Lady Who Stood on Her Head: A Psychiatrist's Stories of His Most Bizarre Cases
As I drove down the deserted Ventura Boulevard at midnight, I worried about Jason. He’d been fine that afternoon, and now he was blind? He was too young for a stroke, but it could have been a bilateral retinal detachment. Maybe he’d hit his head or had some other accident. If Peterson was getting an LP and CT, he must have suspected an infection or tumor. I was surprised that Jason had asked for me, given the way our session had ended. I pulled into the E.R. parking area and walked quickly through the ambulance entrance.
In the waiting room I saw an elderly couple, the man in a wheelchair with apparent paralysis on his right side, perhaps from a stroke. His wife was offering him something to drink. Another family was comforting a little girl who was wincing in pain and holding her arm. In the back I spotted a middle-aged couple arguing. The man looked like an older version of Jason; the woman was brunette and petite, crying and wiping her eyes with a handkerchief.
I went directly to the nurses’ station down the hall, and Dr. Peterson approached me. He was young, probably a physician resident in training, moonlighting in this community-hospital E.R. “Thanks for coming down. Your patient was pretty upset, but his mother was even worse,” he said. “I thought she was about to hyperventilate, so I gave her five milligrams of Valium to calm her down.”
“How’s Jason doing?”
“Actually, we can’t find anything organically wrong with him that would impair his vision, so we’re thinking it’s got to be psychological. He’s in the room at the end of the hall.” Peterson handed me the chart and headed toward the waiting room to call his next patient.
I walked toward Jason’s room, skimming the chart. It was true that all of Jason’s tests had come back negative. As I read the brief chart, it struck me how little E.R. doctors knew about the patients they were treating, yet so often they were able to save them in life-threatening situations.
I saw Jason lying on a gurney, wearing a hospital gown. His eyes were shut.
“Jason. It’s Dr. Small.”
“Thank God,” he said. “Finally, someone who will believe me. I can’t see and no one will tell me why. One minute I could see perfectly, and a second later I was blind.”
“Jason, why are you keeping your eyes closed?”
“It doesn’t matter. Open or closed, I still can’t see a thing.”
“Let me try something,” I said. “Take a deep breath and relax. I’m just going to pull your eyelids up.” I placed my thumbs on his eyebrows and pulled up gently on his lids. As I pulled, he squeezed his eyes shut so tightly that his whole face scrunched up.
This was bizarre. The more I tried to open his eyes, the more tightly he closed them. Peterson’s conclusion was probably right—Jason’s sudden blindness didn’t appear to have an organic cause. Why else would he be resisting my efforts to open his eyes?
“Jason, do you remember what was going on right before you lost your vision?”
“Yeah, I told my father I had decided to go to Berkeley and get my philosophy Ph.D. See? I wasn’t afraid of confronting him.”
“What did he say?” I asked.
“I don’t remember exactly. All I know is, suddenly I couldn’t see and I panicked. Then everybody started yelling. Dad accused me of faking it, but Mom insisted they take me to the hospital.”
“How are you feeling now, Jason?”
“Scared. I mean, I can’t see. The doctors can’t find anything wrong with me, and I don’t think this Dr. Peterson even believes me. You believe me, don’t you, Dr. Small?”
“Jason, I believe that you can’t see, and I’m going to help you. I’m going to go talk with the doctor and your parents for a few minutes, and then I’ll be back.”
I went to the waiting room, which was empty now except for the couple sitting anxiously in the back. “Mr. and Mrs. Riley?”
They looked up expectantly. “Yes?” Mrs. Riley asked.
“I’m Dr. Small, your son’s psychiatrist.”
Mr. Riley stood and shook my hand, “Thanks for coming down here. I knew the moment this started that it was all in Jason’s head.”
“How did you know that?” Ruth Riley asked.
He turned to her. “He’s got his eyes closed, for Christ’s sake. He’s faking it.”
“Alan, you can’t know that for sure,” Ruth said.
“Don’t defend him, Ruth. Let’s see what his psychiatrist thinks.”
“I’m not sure yet,” I said. “But it would help me to know what happened just before he lost his vision.”
Alan Riley sat back down. “Jason had come into my study to talk. It turned into a heated discussion about what he planned to do after graduation.”
“How heated was it?” I asked.
“Jason started the argument: he was all puffed up, telling me that he had decided about graduate school. Since when is it his decision? Is he paying? Besides, we had already made a deal—Loyola Law.”
Ruth spoke slowly. “Alan, it is his decision. You can’t run his life forever. He’s not Robert.”
Alan slammed his hand down on the arm of his chair. “Why are you bringing Robert into this? He has nothing to do with it—”
I interrupted. “What might help is if you could tell me what happened in the very moments before Jason lost his sight.”
Alan took a deep breath while gripping the arms of his chair. “I told him I wasn’t going to send him to some hippie school to study philosophy so he could sit on his ass and teach for forty grand a year.” Despite his efforts to remain calm, Alan’s voice was rising and his face was getting red.
Ruth rubbed his arm. “Alan, calm down, it’s not good for your heart.” Turning to me, she said, “Doctor, they were arguing so loudly that I came running in from the kitchen. I’d never seen my son that angry. He held up his fists and was about to take a swing at his own father. Then suddenly Jason grabbed his face and started screaming that he couldn’t see.”
“That sounds frightening. Alan, is that how you recall it?” I asked.
“I guess so, but let me tell you, if that punk would have tried to punch me, I would have kicked his skinny ass.”
“Don’t be ridiculous, Alan. He’s stronger than you. Besides, you’ve never hit him and you never will.”
As I listened to Jason’s parents, I began to form my own theory of what had brought the Rileys to this point. Over the years, Jason’s obsessiveness and need to control had helped him to manage his anger, especially toward his father. His decision to get a Ph.D. rather than go to law school was not simply a choice but also an act of rebellion, an expression of anger toward his father, who had been controlling Jason throughout his life.
Obsessive, controlling individuals often need to avoid direct expressions of anger because they feel it is too dangerous and could become explosive, which is how Jason might have felt when the argument with his father escalated. When Jason finally confronted his father and unleashed his pent-up rage, he was on the brink of physically harming him, and that was unacceptable—at least at an unconscious level. To stop himself, his mind made him believe he was blind. That way, he could no longer strike out and hurt his father.
It seemed to me that Jason was suffering from hysterical blindness to keep from punching his father. With classic hysterical conversion symptoms, the mind suppresses uncomfortable or unacceptable feelings and thoughts and converts them into physical symptoms. The physical symptoms have both a primary and secondary gain. The primary gain is the avoidance of some conflict or feeling. In Jason’s case, he avoided striking his father and suffering the consequences of that action. The secondary gain of the hysterical symptom is the attention and comfort the patient receives as a result of the hysterical illness. Both the primary and secondary gains associated with conversion hysteria serve to reinforce the physical symptoms, making them persist, sometimes for months or years. As with most acute-onset illnesses, whether they have a psychological or physical origin, a rapid intervention is usually most effective and can prevent the emergence of chronic problem
s.
If my theory was correct, then I needed to help Jason consciously acknowledge his anger toward his father and find a way to express it without physical violence. Expressing his anger would detoxify it, making it less dangerous, and eliminate the primary gain of his hysterical blindness. I felt my best shot was to get all the Rileys into the room and help them confront their issues. One in the morning was an unconventional time to have a family session, but the key players were here, and I felt a sense of urgency.
We all pulled up chairs around Jason’s gurney, and I helped prop him up into a sitting position for our makeshift family meeting.
“I know it’s late and everybody’s tired,” I began. “But we need to talk about what made Jason lose his sight tonight.”
“So the tests came back positive!” Jason said.
Ruth piped in, “You see, Alan? Things aren’t always what they seem.”
“You’re right about that, Mrs. Riley,” I said. “But the tests were negative.”
“What do you mean?” Ruth asked.
“It’s true that Jason can’t see, but it’s not something physical making him blind, it’s his mind making it happen.”
Alan spoke up. “So it is all in his head! You can snap out of it now, son. Just open your eyes.”
“It’s not so easy, Mr. Riley,” I said. “The key to Jason’s blindness is why his mind is doing this to him.”
“I don’t understand,” Alan said.
I wanted to get Jason into the conversation, so I phrased the next question in a way that would appeal to him. “What purpose does it serve Jason to be distracted by this physical symptom?”
As I had hoped, Jason responded, “I think I see where you’re heading, Dr. Small. What’s your theory?”
My strategy here was to get Jason to express his anger toward his father in a safe way. He didn’t necessarily have to understand why he went blind, but we were already down that road and it appealed to his intellectual defenses.
“Jason, for a good portion of your life, you’ve been angry at your father and you’ve had no way to express it. You resent his trying to control you.”
“That’s ridiculous!” Alan blurted.
“Be quiet, Alan,” Ruth said. “Let the doctor finish.”
I went on. “I believe your father loves you and wants the best for you, but you two see things differently. And the big problem for both of you is that you avoid talking about your feelings. If you could learn to talk, you wouldn’t feel the need to hit, and it will feel safe.”
“That’s an interesting hypothesis, Dr. Small, but how do you prove it?” Jason asked.
Before I could answer, Alan interrupted. “The burden of proof is on you, son. Just open your damn eyes.”
I ignored Alan’s comment. “Jason, let’s try this. Tell your father how angry you are at him. Nobody’s going to get hurt; I’m here to make sure of that.”
Jason laughed. “I’m supposed to just talk about a lifetime of being ignored and controlled, and then forced to stand in for my dead brother.”
“Jason, how dare you say that?” Ruth scolded.
“Because it’s true, Mom, and Dad knows it.”
“What I know is,” Alan yelled, “you’re not half the man Robert would have been.”
“See, Dr. Small? That’s exactly what I’ve been talking about,” Jason said.
Alan shook his head. “Tell your shrink whatever you want about me, but I’ve tried to give you the best life I could.”
“I’m sure you have, Mr. Riley,” I said. “But before you and Jason can have a real relationship, you’ve got to grieve Robert’s death.”
“Don’t tell me about grief. I lost my future when that boy died.”
“But you still have another son, another future,” I said.
“I know that, but Robert was an amazing kid—we had a special connection. He reminded me of myself when I was young. He’d come to work with me on the weekends, and we’d discuss cases. He would have been a better lawyer than I ever was.” He paused for a moment as he reminisced, no longer angry but sad. “I did everything for him; I got him everything. Why’d I have to get him that damn sports car?”
“Alan, do you feel responsible for Robert’s death?” I asked.
Alan hung his head and covered his eyes. Ruth started to sob.
“Wait a minute,” Jason said. “I thought Robert was killed by a drunk driver.”
Ruth said, “We only made up that story to protect him.”
“What are you talking about?” Jason asked.
His father looked down. “It was Robert who had been drinking, and he crashed into a tree.”
Jason bolted straight up on the gurney and glared at his father. “You mean you’ve been lying to me all these years?”
“We didn’t want you to hate your brother.”
“No, you’d rather I be him and grow up to hate you.”
“That’s not fair,” Ruth said. “We love you, and I don’t believe that you could ever hate your father.”
Jason’s face turned red with anger, and I noticed that his eyes were wide open. He seemed to be seeing just fine. “Jason, can see your father right now?” I asked.
He looked at me. “Yes, I can, finally.” He turned back toward his father. “But I’m still angry as hell.”
“You can see, sweetheart!” Ruth gasped. “Thank God. That’s what’s important. Darling, please don’t be angry anymore.”
“Leave him alone, Ruth. He’s right to be angry. We never should have lied to him, and if I hadn’t pushed Robert so hard and put so much pressure on him, he might still be alive.”
The moment that Jason put his anger toward his father into words probably freed him of his psychological need to be blind. The emergency family-therapy session seemed like a miracle talking cure, but soon after the session ended, Jason again clamped his eyes shut and couldn’t see again. I admitted him to one of the UCLA psychiatric inpatient units, and we continued family sessions in the hospital for the next two weeks. Jason’s father finally came around and said he’d support whatever career choice Jason made. Gradually Jason’s psychosomatic blindness cleared up for good.
After his discharge from the hospital, Jason continued his weekly therapy with me. A few months after the hysterical-blindness incident, he entered my office a little late for his appointment, which I interpreted as one of several measures of his progress. He apologized for being tardy and lined up his items in the usual way.
“So how are you getting along with your folks these days?” I asked.
“Dad still needs to be in control of every conversation, and I continue to ignore him. It’s typical of the dilemma of the human condition.”
I raised my eyebrows, “Typical of the human condition, Jason? Get out of your head and talk about your feelings.”
Jason laughed. “Oh, yeah, he pissed me off again when he went on one of his Republican rants last night.”
Jason was still obsessive and controlling, but less so, and his therapy had progressed. He was beginning to recognize when he was intellectualizing to avoid feelings. His relationship with his parents was better—he was able to stand up for himself and express his feelings in words, so he had less need to act them out. Eventually, he trusted me enough to try an antidepressant, which reduced his obsessiveness.
“Is it getting any easier to talk with your father when he makes you angry?”
“I guess so.”
“What do you think has changed?” I asked.
“All along I felt like there was something wrong with me for being so angry at him. But that night at the hospital when he admitted that he lied and that he was wrong, he became a real person to me, not such a stranger. He became my dad. Not perfect, not infallible. Just my dad, and that’s cool.”
I was about to explore this more deeply when Jason changed the subject. “By the way, school is going great.”
“Oh yeah? What happened with that new class you were trying to get?” I asked.
>
“Oh yeah, torts,” he replied. “I got in and we’ve got a terrific professor. Did you know that the Latin root of the word tort means ‘twisted’?”
“Really,” I said. “That’s interesting.”
“We’re trying to understand the legal rationale behind decision making. I love that…”
Once Jason came to grips with his anger over his father’s meddling, he realized that his decision to get a philosophy degree was partly to rebel against his father. When his father backed off, Jason discovered that he did have an interest in law, and he was drawn to it with the same intellectual curiosity that drew him to philosophy. Of course, he still might disappoint his father one day and become a public defender instead of a partner in Riley & Riley, LLC.
When I think about Jason’s case, I believe that watching his father come to terms with his guilt over Robert’s death was perhaps the most powerful therapeutic moment for Jason. Rather than becoming a crippling and chronic disability, Jason’s sudden loss of vision became an opportunity to talk about his true feelings and get closer to his family. He continued with psychotherapy and antidepressants for several years and showed improvement, but many of his deep-rooted obsessive-compulsive traits remained.
Though hysterical blindness is a medical rarity, the conflicts and feelings that fueled Jason’s episode are not. How often do we hold back and avoid expressing our anger to preserve a relationship? And what about those people who just let their rage flow out whenever it pleases them? Some get away with it, others learn to keep it in check and suffer, and still others find a healthy way to express it. Jason’s question about free will was a profound one. We all have free will, but only when we open our eyes and face the realities of our past and present are we able to make the most of it.
CHAPTER TEN
Brain Fog
Summer 1990
GIGI AND I HAD MOVED TO Studio City, about a forty-minute commute to UCLA. On weekends, we often went to the movies at Universal CityWalk, a replication of Los Angeles within Los Angeles. Why people couldn’t just walk down the real streets of Los Angeles made no sense to me, yet there we were, on a Friday evening, eating ice cream and strolling down a simulated street.