“His famous formulation was that you acknowledge, bear, and put into perspective the patient’s feelings and experiences. But notice that the first two, by far the most important, draw not on intellect but on emotion. People in the Institute mocked him. But he didn’t care, or at least he said he didn’t.”
“It had to hurt his feelings,” I said.
“It probably did,” Les replied, “but people also loved him. He didn’t care about that, either. He just wanted to teach and impart what he knew about helping people. And he knew a lot. He just didn’t play their game. He didn’t have the turf to protect that the Viennese did. He didn’t like to fight, so he’d go to meetings and allow all the smarty-pantses to win. But he won the battle for what matters most.”
Havens went on, “This is why innovation in our field is so difficult. Everyone is protecting turf and attacking anyone who proposes anything new. Heinz Kohut is a good example. When he wrote The Restoration of the Self, which stressed empathy in treating narcissism, the classical analysts went ballistic. If you ever want to read a truly savage review, a cruel and completely gratuitous attack, read Harold Blum’s review of that book in the Journal of the American Psychoanalytic Association. Kohut was old, and I truly think that review is what killed him.”
I could see from what Les told us that my analyst, Khantzian, was more Kohutian, more Semradian, than Viennese. That made sense, since he had trained under Semrad.
I would also learn, mostly from Les, that what I had hoped to do at MMHC—explore the deep recesses of the human mind—was more the purview of a psychoanalytic institute than a state mental hospital. We were learning psychiatry, not psychoanalysis.
I was at a juncture as a second-year resident. If I wanted to pursue psychoanalytic training, now was the time to start. Most of us harbored the ambition of getting analytic training—it seemed to be the gold standard if you wanted to be a deep student of human nature.
But even if I had been able to afford the time and money (I couldn’t), I had to look at myself and say, You’re not analyst material. You’re too impatient. You can’t sit still and listen that long. You can’t not say what you want to say long enough for the patient to ramble on, freely associating.
I had to look no further than the annual MMHC dinner for evidence. At the end of each year, the hospital held a dinner at the Harvard Faculty Club to celebrate the year and bring us all together. Each year there was a guest speaker, some luminary in the world of academic psychiatry. I looked forward to these lectures, as they were usually excellent.
One year, however, the speaker, despite his international renown, was awful. He was mailing it in, with no end in sight. I literally could not sit still for it. As I happened to be sitting next to a window, without giving it a second thought, I opened the window and jumped out. Fortunately, the banquet room was on the first floor, so I landed safely with no injury and walked away, relieved to have escaped intolerable boredom.
It was also fortunate that the table I was sitting at was in a corner, out of sight from the big shots at the head table. A psychoanalyst cannot jump out the window if his patient bores him, and every patient in analysis must at one time or another bore his analyst. But I had to be honest. Even though I yearned to be a psychoanalyst, I would have hated the actual job.
Dr. K. agreed with me, although he didn’t come right out and say it. Instead, he said, “It’s not for everyone.”
All the same, I would read the description of analytic training and think, What could be better than that? But it’s a journey I will never take.
How much they must know, these modern-day Yodas. No longer in the stranglehold of the Viennese, I like to believe they are cut much more out of the cloth of Kohut, Havens, and Semrad now than ever before.
Les Havens, one of the greatest teachers to ever come down the pike—not only in psychiatry but on the subject of human nature in general—died two days before his eighty-seventh birthday in 2011.
62.
Karen sat in a chair in my office picking at her clothes, looking at the wall, the floor, here and there, like a bird on a wire. She was dressed in layers: gray shirt covered by red shirt covered by plaid jacket; jeans covered by green tattered skirt; bright white sneakers she must have just found in the clothes depository; gray wool socks; various gold-colored chains around her neck; a knitted rainbow-colored beret-like hat over her caked-down black hair. She had a torn paper shopping bag full of this and that at her side.
One of the “experienced” patients at MMHC, Karen had been teaching residents for years. Now in her forties, she’d been assigned to me. In years to come, she’d leave the hospital thanks to the miracle drug Clozapine. But in 1979 we didn’t have that yet in the United States. (It was available in Europe, but the wheels of the FDA grind slowly.)
Karen was quietly psychotic. My job was to forge a relationship with her. I was to do this by using that time-honored method Dr. Semrad championed: sitting with her.
Karen couldn’t communicate, at least not with words. I had to intuit what was on her mind. In addition to sitting with her, Karen’s therapy included prescribing antipsychotic medication, which did help somewhat. I also decided what privileges she could have, i.e., how much freedom she got to roam the hospital, even to leave the hospital if she seemed able to handle the responsibility.
I was learning the value of sitting, the value of connecting.
I learned from Karen what it feels like inside me when I cannot converse with another person, even though she speaks English. It feels frustrating, aggravating, and sad. Semrad would call this “the empathic diagnosis.” By noticing what I am feeling, I may be getting in touch with what the patient is feeling. Or I may not. There’s no proving it one way or the other.
But I was taught—and I obeyed—not to do what I most wanted to do: terminate the session because it was pointless. That would be denying the value of the patient’s time and reality. Wasn’t Karen as entitled to my attention as a patient who could converse meaningfully with me?
I kept sitting. I would watch Karen, listen for whatever she might say, cross and uncross my legs … and gradually come to see the point in it. Karen would mutter phrases, many taken from old advertising jingles, that were perhaps like rosary beads to her; phrases like, “Ivory soap floats,” “M&Ms melt in your mouth, not in your hand,” or “You’re in good hands with Allstate.”
I’d try to play off one of those and see if I could strike a chord. For example, one day when she muttered, “You’re in good hands with Allstate,” I said, “I bet you really hope you’re in good hands here.”
She made no reply and went on, leaving me to wonder what she did with what she heard. That’s the mystery of the psychotic mind. Most people would say she did nothing with it, that my words meant nothing and had no impact.
Weeks later, I would learn differently in the Community Meeting, the biweekly meeting of our unit’s patients and staff, which was run along the lines of a Quaker meeting.
Karen, out of nowhere, spoke up and proclaimed, “We’re in good hands here!”
People’s jaws dropped. Professor Stein, the ex officio patient leader, said, “Karen, it’s so good to hear from you!”
Karen didn’t respond but just kept looking around like a bird, as she always did. Still, it was a stunning moment, at least for me, and, I could tell, for Professor Stein.
I met with Karen weekly. She regularly earned privileges to leave the hospital on group walk—which she enjoyed, it’s when she could buy her cigarettes—as well as earned privileges to go to a halfway house for overnights.
At that, she balked. No overnights for Karen. She’d developed what I learned was called an “institutional transference.” Nonpsychotic people do this when they fall in love with their alma mater, for example, or, like me, with the team they root for, or the city they live in; institutions that have no feelings get treated as if they do have feelings, as if they were people who cared in return.
In Karen’s case,
the transference was with MMHC. When she gained privileges to sleep outside the hospital, she’d eschew the halfway house and instead dig a hole up against the cement foundation of MMHC, curl up, and sleep in that hole. The police had grown accustomed enough to it that they let her sleep there unless the weather was too cold or wet, in which case they’d call us to bring her inside.
One night I was the one on duty when the call came in to go outside and get Karen. The sight of her curled up in the hole she’d dug for herself, wrapped in her many layers of motley attire, etched an image in my mind I’ve carried ever since. Talk about a safe place; even though it was against an inanimate slab of concrete, Karen had found hers. She was sleeping as peacefully as an old hearth dog, in good hands.
63.
Early in my first year at MMHC I attended a Grand Rounds given by one James T. Hilliard. All I knew was that he was an attorney, and we were required to attend his presentation on risk management.
I went in thinking this was going to be a total waste of time. I didn’t need to be bothered with laws, did I? Just do your job the best you can, treat patients with care and respect, and you’ll be fine, right?
In less than an hour I was reduced to a trembling pool of petrified protoplasm. Jim, a low-key, obviously smart and experienced attorney who knew his stuff cold, began by saying to us newbie psychiatrists, “It’s not too late. You can find another career and never worry again about what I’m going to tell you. The fact is, if I were you, I would get out now. I couldn’t stand living with the risk you all take on every day just by walking into the hospital. Then, when you see patients and start signing your name, the risk goes through the roof.”
This guy was not putting on a performance. He was telling us about life as he lived it every day, defending doctors who were being sued, showing us what we didn’t see since we were just clinicians, not lawyers. He was urging us to wise up, to stop pretending that everything works out for the best as long as you are a good boy or girl, and if we were not taking his advice and leaving the practice of medicine altogether, then at least we should take very seriously the dangerous spots we put ourselves in every day. I learned terms I’d never heard before, like “deep pockets.”
“That’s a legal term?” I asked.
“Yes,” Jim said. “People who sue people want to sue people who have deep pockets, or who have insurance that has deep pockets. You understand what I mean? People want to get a big judgment so they can retire because of your mistake.”
He went on to tell us about the dangers of insufficient documentation (“If it isn’t documented in the chart, it never happened”), failure to communicate with patients (“Doctors who don’t take the time to listen to a patient’s complaint are the doctors who get sued”), flying solo (“When you start believing you know more than everyone else, that’s when you get in trouble”), having sex with a patient (“Don’t do it, don’t do it, don’t do it”), forgetting to ask about suicidal thoughts (“If a depressed patient commits suicide and you haven’t documented that you asked about suicidal thoughts, you are exposed to a wrongful death suit”).
Jim was so convincing that I wanted to start carrying a tape recorder with me everywhere I went. I wanted to document every interaction I had, every thought that crossed my mind, every word and action from every patient. In that hour I learned to fear my job, fear patients, fear the legal system, fear attorneys, and most of all, fear my own fallibility.
I’d be much safer, I thought, if I quit then and there and applied to law school. An attorney who also has an M.D. is a hot commodity. I could make a lot of money defending doctors, maybe lobbying to get the laws changed, finding ways to tackle the injustice of it all, while protecting myself from the seeming inevitability of getting sued (“It’s not if you get sued,” Jim told us, “it’s when you get sued”).
It was a short-lived reverie. My lot was cast. Still, after hearing Jim Hilliard’s talk, I never felt the same as a doctor. An element of fear seeded my system that some would say was good—Bill Clinton once commented that suing doctors is good “because it keeps them on their toes”—but I knew for a fact it was bad. Doctors fearing patients is as harmful for medicine as patients fearing doctors.
But from that day forward, I had to learn to live with it. We all did.
64.
“I hope I’m not being too cynical, but—” I said to Dr. Taube, my supervisor on outpatient cases.
“You cannot be too cynical,” Dr. Taube interrupted. “Your problem is you’re not cynical enough. But I can help you with that,” he said with a wry smile. “I am a master cynic.”
Irv Taube was a shortish man, always impeccably dressed in a suit, usually Brooks Brothers wool or gabardine, with beautifully contrasting shirt and tie, who carried an elegant, brown (not black) leather doctor’s bag with him everywhere. He had trained at MMHC back in the heyday of Semrad but didn’t glorify those years. In fact, he didn’t glorify much of anything. His view of life was dour at best. And yet he loved teaching.
Irv was short for Irvin, not Irving. Like his doctor’s bag and his name, Irv did not fit any mold. He appeared vain but wasn’t. He appeared soft-spoken but was highly opinionated. He appeared slight but was strong as an ox. He often appeared to be distracted but paid rapt attention. He claimed to know little and have few answers, but he knew a lot and had buckets of answers. I looked forward to every meeting with Irv just for the experience of being with Irv.
I had started my fellowship in child psychiatry, but we were given one supervisor for the adult cases we had, and Irv was mine. We met at “the lunch hour,” as he called it. After I arrived, he would carefully extract his meal from his bag. “I hope you don’t mind if I eat? It is the lunch hour,” he’d say. “Please feel free to bring your lunch next time.” And I would always reply, “Of course, please do eat. Don’t worry about me, I usually skip lunch.” It would be unthinkable for him to pull out lunch while meeting with someone who was not eating lunch without first asking that person’s indulgence.
Once in a while, he would caution me, “You shouldn’t skip meals. One of the bad habits doctors get into is not taking care of themselves. They get so wrapped up in taking care of their patients that they neglect their own needs. And you know what that leads to, don’t you?”
“Bad stuff,” I said.
Irv smiled and nodded, but ever the Socratic teacher he then asked, “Could you be a bit more specific?”
“Burnout.”
“Yes, but what else, more common than burnout? Most doctors are too driven to burn out. Instead they just keep dragging along, dreading every day, but showing up just the same. But what else do they do when they neglect their own needs?”
“They get them met in dangerous ways, like drinking too much, taking drugs, going in on harebrained financial deals, having sex with the wrong people?”
“Yes, exactly,” Irv said, carefully wiping his mouth with a napkin. “If you don’t get it where you should, you get it where you shouldn’t. That’s my long version of telling you not to skip meals. Why do you skip lunch, by the way?”
“I want to lose weight,” I admitted.
“I thought you were going to say because you’re too busy. I’m glad you didn’t play that card. You want to lose weight? Why? You look like you’re in good shape. Do you get exercise?”
“Yes. I play squash with Peter Metz every week.”
“Oh, good. You know I supervise Peter as well? He is a very smart man.”
“He’s my best friend,” I said proudly.
“Well, you have good taste in friends, then. He is not only smart, but he is a good person.”
“I agree,” I said. “I will tell him you said so.” I always tried to relay compliments, as MMHC teemed with backbiting, nasty gossip.
“Before we talk about your case, I would be remiss if I didn’t tell you that skipping meals is no way to lose weight. You have to change your eating habits. But you don’t need me to tell you that, do you?”
> “You’re reminding me of what I know. I’ll do my best.”
“Good,” Irv said. “So what’s going on with Mr. Sloan?”
I’d been presenting a Northeastern senior to Irv for the past couple of months. He was twenty-two years old and he’d come to the clinic because he was struggling academically. He’d seen a therapist over the summer at his home in Virginia who’d diagnosed him with depression and put him on an antidepressant. I had continued the medication but was trying to go deeper into his issues. “He seems to be doing all right, but he is still struggling. He works really hard and should be doing better.”
“What does he want from you?” Irv asked.
“He wants relief. He wants to do better with less work. He wants to be happier,” I replied.
After taking another bite of his sandwich, which appeared to be chicken with lettuce and mayo, Irv asked, “And what do you want from him?”
I was taken aback. No supervisor had ever asked me that question. “I don’t know. I’ve never thought about what I want from him.”
“Really?” Irv said. “Actually, I am not surprised. It’s not common for a supervisor to ask a trainee what he wants from a patient, is it?”
“No, it certainly isn’t.”
“But why not?” Irv asked, rhetorically. “This is life, after all. When a patient meets a doctor, and a doctor meets a patient, the larger rules of life still apply. I know you like literature. Do you remember the line in Heartbreak House, ‘Do you think the laws of God will be suspended in favor of England because you were born in it?’ Well, I sometimes think around here people think the laws of human nature will be suspended in favor of psychotherapy because we practice it. In every human interaction between two people, each person wants something. Never forget that. It is a fundamental law of life.”
“That sounds so cynical,” I said.
“I told you already I’d teach you to be more cynical. Honestly, Ned, I am just trying to help you get over your naïve assessment of human nature. It’s wishful thinking. I hate to tell you, but it is. And it will get you into trouble, if it hasn’t already.”
Because I Come from a Crazy Family Page 28