“No,” Melanie said.
When I looked over my shoulder, Melanie backed up a few steps. She was a younger woman but with the worn look of a person who’s been taking antipsychotic medications and battling mental monsters for many years. I didn’t know her well, as she was not my patient, but she had an innocence about her that I’d come to learn many people with chronic schizophrenia shared. The ordinary citizen often fears chronic schizophrenics, but the average banker is far more dangerous.
“Dr. Hallowell, I would like to borrow two dollars from you,” Melanie blurted out, then backed up another step.
I reached into my hip pocket for my wallet and looked inside. It was empty of cash. “Gee, Melanie, I don’t have any cash. Sorry.” The other three bridge players were listening closely to this conversation, as it was not customary for patients to ask doctors for loans, nor for doctors to check in their wallets in response. If I’d thought about it, I probably would have realized that not lending patients money was another unwritten rule I should have known about.
Instead, I blundered on ahead, guided by instinct and an inbred tendency to be polite. “Do you have privileges to leave the hospital?”
“Yes,” Melanie said.
“If I were to give you my ATM card, could you go across the street and withdraw some money from my account? You’d save me a trip, and you could keep two dollars for yourself.”
Melanie broke into a big, sweet smile, revealing her dire need of dental work. “You’d do that?”
“Yes, I would do that. I believe I can trust you.”
“Oh, you can. I will be sure to be very careful. You can trust me for sure.”
I took a scrap of paper from my wallet—I always have scraps, as scraps are one of my main tools of organization—and wrote down my password for Melanie, which I then handed to her along with my bank card. “Take out fifty dollars, OK?”
She received the card and the scrap of paper with two hands, then carefully put them into her jeans pocket. “Thank you, Dr. Hallowell,” she said, looking flustered, then made her way to the door and off the ward.
“Doc, are you crazy?” Professor Stein asked. “She could empty your account and get on a bus to Kansas. You may never see her again.”
“I don’t think she will do that, Paul. I think I can trust her.”
“That’s nice of you, but do you know that you can trust her?” one of the other players asked. “She’s here for a reason. She’s crazy.”
“Good point,” I said. “On the other hand, I think she will rise to the occasion.”
“But you don’t know that,” the player replied. “And what will you do if all of us start asking you for money? Have you thought of that?”
“I actually hadn’t thought of that. I hope you don’t.”
“We shall see,” Professor Stein pronounced. “Now, let’s get back to the game!”
As I considered my next bid, I realized I had just made what pretty much everyone would call a huge mistake. I anticipated telling my supervisors about it and being read the riot act. “Are you nuts?” I imagined them saying. “Have you never heard of boundaries?”
Jumping to three hearts in response to the professor’s opening bid of one heart, I quietly asked myself why on earth I had given Melanie my credit card. It was impulsive, not at all the result of deliberation. Why would I cross the boundary between staff and patient so blatantly?
An answer came to me, which I hoped was not merely a defensive rationalization. I thought the patients in general were capable of handling far more responsibility than we gave them. Melanie, in particular, who’d earned privileges to leave the hospital, would benefit from being given my trust; it would amount to a therapeutic intervention, not a foolish crossing of boundaries.
And why do we have to be so insistent on what separates us from our patients? I mused to myself, watching the professor take us to six hearts without even asking for aces. We’re forever putting ourselves in charge of them in the name of protecting them and encouraging them to earn the right to leave the hospital and set their own boundaries. But, Ned, remember that in your upbringing the only boundaries you ever learned about were the ones studied at school in Geography. In Psychiatry, they matter a whole lot more than you realize.
As I carried on this internal discussion and watched the professor make our small slam, God, or whoever protects us all, smiled on me, because in twenty minutes a beaming Melanie came back onto the ward, gave me my credit card and forty-eight dollars, and told me she kept two dollars for herself. “I made change at the 7-Eleven.”
“Thank you, Melanie,” I said. She moved toward me and I thought she was going to hug me, but she stopped short, turned, and left the floor.
The story made the gossip grapevine of the hospital. While some people thought I was out of my mind, the most senior supervisors congratulated me on making a calculated, bold move. (They didn’t know it was far from calculated but rather purely spontaneous.) “It worked,” one said. “That’s what counts.”
In the early 1990s Melanie would be one of the first patients at MMHC to get on the new medication, Clozaril, which would revolutionize the treatment of chronic schizophrenia because it led to dramatic improvements never seen before. Decades later, she wrote to me at my request. She remembered my giving her my ATM card, and told me that my trust had meant a lot to her. She added the following account of her life, which she sent me so that I could include it in this memoir:
I was diagnosed with schizophrenia in 1964. I was sixteen. I spent decades and decades of my life wishing I had never been born.
Those were the dark ages of mental health care. Lobotomies had not yet been renamed psychosurgery. ECT was in a primitive state with being tied down to prevent broken bones and having a rubber mouthpiece in your mouth to keep from gnashing out one’s teeth. I experienced shock treatments under the duress of threats to confine me indefinitely. For years afterward I had to make the most simple lists for each day. The list would say things like brush your teeth, get dressed, have cereal.
The hardest part of having schizophrenia is relationships. I looked OK … men were definitely interested … but my personality was completely undeveloped. I had no defenses or boundaries with men. I exacerbated these symptoms by using LSD, marijuana, and cocaine. These had a terrible effect on my ability to communicate either in writing or speaking.
I had no character or integrity to speak of … I just wasn’t motivated to be a better person … I was in too much emotional pain to care. I didn’t want to live. Twice I overdosed seriously enough to land in a hospital ICU. There were many other times I took all my meds. I found out that being poisoned hurts.
I discovered that cocaine could alleviate a condition of not experiencing pleasure.
There is a medical term for this condition. This was the result of dopamine inhibitors. Cocaine didn’t so much as get me high … it just made me normal.
Pursuing drugs, overdoses, experiences of actually escaping from a strait jacket and also from leather four-point restraints I was, looking back, a good kid. I will never forgive myself for the pain I put my parents through.
At MMHC we had sing-alongs, poetry classes, and I sang loud and off-key but it inspired me.
I met my husband of 27 years in the locked unit at Mass Mental. I had never had a relationship that didn’t cave in due to my diagnosis. Hank never abandoned me or judged me for being a deficient human being. After all, he too was diagnosed with schizophrenia.
We clung to one another as if in a hurricane. We were homeless and had many experiences of hardship like sleeping in cars when it was freezing out … other people were often kind to us. Eventually we got housing.
Thorazine had been a breakthrough enabling people to stay in their homes, helping to make strait jackets obsolete. The side effects of the “zene” medications were weight gain, tardive dyskinesia, loss of coordination and sluggish mental ability. I was on average a pretty and well co-ordinated young woman and the option o
f becoming like the Bride of Frankenstein on huge doses of Thorazine was impossible to accept.
I would become psychotic, go in the hospital, be given Thorazine (or later Stelazine, Prolixin, Haldol), and calmed down. This meant I would stop trying to set gas stations on fire or chasing women with baby strollers down the street while thinking their mothers were kidnapping their own little ones.
As soon as I was released I would go off the meds, lose the twenty to thirty pounds I had gained while on medications and have another successful six months to a year and then be back in the hospital, beginning the cycle over again.
In 1993 I was given Clozaril in a study conducted at MMHC and it worked as nothing before it had worked. My pleasure centers weren’t as frozen as with dopamine inhibitors, my thoughts became fluid again and I was able to begin making a life for myself. I was for the first time able to be compliant with my treatment. I have had, thanks to this study, twenty-two good years. Now I want to give back.
I graduated from Johns Hopkins with an MA in the Writing Seminars in 1970. A big part of my life now is writing poetry … I have published three books … and continue to work and study and quite often am published in little magazines.
Hank and I somehow survived each other and have grown into a supportive and loving couple. This would never have happened without the support of my therapist who worked with me on establishing boundaries and pursuing my goal of investing emotionally in this relationship which most caregivers saw as a liability. I cannot imagine being happier in a true, equal relationship.
I spend quite a lot of my time volunteering at Mass Mental on the Human Rights Committee and also, working with others with lived experience of mental illness, serve on the Consumer Advisory / Commonwealth Research Center committees.
Every day is a full one and I am never bored. I was given Clozaril as part of a study conducted at MMHC, a study which gave me my life back.
All those years of intense suffering have left me a very grateful and appreciative and mostly happy individual.
I work on myself spiritually, morally and I believe I have achieved a fairly good outcome as far as character is concerned.
59.
One of the ways we learned our craft as residents was to present cases to senior clinicians, our supervisors, our teachers, in a group setting. One resident would present the story of one patient or family, and then the supervisor would interview the patient, with a discussion to follow.
These were not only valuable for our learning, but they gave the resident a chance to strut his stuff, or look foolish, or some of both. There was usually an audience of over thirty people, as all disciplines were invited.
One day I happened into such a conference just as it was beginning. The supervisor was Nick Avery, a brilliant man we all looked up to and upon whose every word we hung. The presenter was a resident named Peter Metz, a tall, trim, slightly balding man who had been at Harvard with me.
However, seeing Peter present now was my first significant exposure to him. One time in the coffee shop I’d mentioned a patient’s blood urea nitrogen and creatinine levels to someone I was talking to, and Peter had leaned over and told me you don’t really need to get both BUN and creatinine to assess renal function, that it was a waste of money. He was right, but it was a gratuitous, one-upmanship remark.
“OK, thanks,” I’d said, hoping not to see him again anytime soon.
But now, as Peter talked, I became anxious. Although I hide it, I am a highly competitive person, and I could tell right away that Peter was not giving the usual patient presentation. He was presenting the real person, offering telling details that brought his patient to life. She was a massively obese woman who suffered from a chronic mental illness that was not quite schizophrenia, not quite bipolar, not quite depression, and not quite the consequence of a low IQ. She was a bit of all of these and more.
First-year residents were forever searching for what we called “therapy cases,” since most patients under our care had chronic, severe mental illnesses. They were not amenable to insight-oriented psychotherapy, which is what we wanted to do. We didn’t fully appreciate that we were at MMHC to get training in psychiatry, not psychoanalysis.
We were eager to treat people like us: well-educated, motivated, insightful, civilized, well-behaved, and neurotic. Neurotic did not have a precise meaning; generally, it meant not quite happy with life even though you probably should be, given your external circumstances. We wanted to learn how to talk with these people and help them become happy, which is exactly what we wanted for ourselves.
Peter had done what Semrad advised: He’d sat with his patient long and hard and come up with enough dynamic material to transform her from the inert lump other residents had treated her as to a woman who wrestled with conflicts we could all identify with.
It was a masterful job on his part, brilliant in fact, taking both immense imagination and smarts as well as hours of hard work and prolonged listening. I’d never seen anything like it. His work with this patient challenged all of us to find the “therapy case” in our patients.
I remember saying to myself, “Either I have to kill this guy or become his friend.”
I chose the latter. Putting aside his remark about BUN and creatinine, I went up to him and congratulated him on his presentation. I quickly saw how deeply modest and self-effacing he was. Even though we were different in style—he was reserved, I was flamboyant—we took to each other right away.
And then we stumbled onto an idea that changed our lives. “Do you play squash?” one of us, I can’t remember which, asked the other. “Yes,” came the reply.
We set up a weekly squash game. Since Peter and his wife, a pediatric cardiologist, moved an hour away to Worcester after he completed training, later on our game was biweekly. On the same afternoon, Peter would come in to play squash and have his piano lesson. (He is a virtuoso pianist.) After our game, we’d go out for a few beers and talk about cases, and our lives.
Peter and I have been playing squash and drinking beers on Tuesday afternoons for thirty-seven years. He is godfather to our daughter, and I am godfather to his. We are each other’s best friend.
60.
Leston Havens let us residents use his office in the evenings to run group therapies. (We used to say, “Les is more.”) Havens himself did not do groups. “I have a hard enough time keeping track of what’s going on in the mind of one patient, let alone eight,” he said. “But be my guest.” It was typical of the esprit de corps of MMHC that a senior professor, an illustrious figure, would lend his office to us lowly residents to practice a treatment he didn’t even think worked.
Since I was new to everything, I was new to group therapy, as was my co-leader, Jennifer Stevens. Actually, that is not quite true. I’d been learning about therapy for over a year since I’d started seeing Dr. Khantzian as a patient in psychoanalysis during internship. And I was learning about group therapy in the group run by Max Day that we were all required to participate in.
What I was new to was the practice of doing therapy myself, group or otherwise. We residents were encouraged to ask someone from a different discipline to co-lead groups with us, so I had asked Jennifer, who was an OT, or occupational therapist, on the inpatient unit. Because I liked her, it almost felt like asking her out on a date.
The supervisor of the group program, Bessel van der Kolk, who would go on to become a world authority on trauma, had assigned Dr. Allan Hobson to be our supervisor. A professor at Harvard Medical School, Allan was famous in his own right, doing pioneering research into sleep while also trying his best to debunk Freud’s theories about dreams. Not just a biological psychiatrist, as I would learn, Allan was also a brilliant and intuitive therapist. Jennifer and I met with him briefly before our first group meeting. He just told us to jump in and see what happened. My kind of guy!
We had eight outpatients in the group, which had been running for years before we inherited it from another pair of group leaders who’d move
d on to the next step in their training. It was yet another example of how patients helped us out, putting up with losing the group leaders they’d gotten accustomed to and getting to know new leaders just so we could get training. What the patients got in return was a low fee, but I often wondered if we shouldn’t pay them.
Despite Havens’s skepticism, running a group was a requirement in our training. Some of the group supervisors could be pretty dogmatic, if not ridiculous. For example, one day I was walking down a corridor of the hospital when I passed an open office door. Pausing, I looked in.
There was Dr. Joyce Baker, a fellow first-year resident, sitting by herself in a straight chair in a circle of eight other straight chairs, all of them empty.
“What are you doing?” I asked.
“Shhh. I’m not supposed to talk to anyone except the members of the group.”
“But no one’s in the group. No one’s here.”
“It doesn’t matter,” she whispered, as if the ghost of her supervisor might hear her. “I’m here. And I’m supposed to sit here for the full hour and fifteen minutes, whether someone else comes or not. My supervisor says it’s still a group, even if I run it alone. I’m supposed to sit and feel what it’s like.”
“Feel what it’s like to run a group therapy with no one in the group?”
“Yes! Now go away.”
“Joyce, would you like me to join your group?” I volunteered. “I’d be glad to be your patient in group therapy. Then you could tell your supervisor you had at least one member.”
“Ned, you’re bad. I can’t do that and you know it. I’m not even supposed to be having this conversation.”
“Like this is a forbidden interaction? Forbidden interactions should be juicier than this!”
“Stop it!” Joyce said in a loud whisper.
“Joyce, this is absurd. You’ve gotta agree. It’s like a scene out of an Ionesco play.”
“What kind of play?” Joyce asked.
Because I Come from a Crazy Family Page 26