“I’m sure you’re right.”
“So let’s come back to your patient. Think for a minute, what do you want from him?”
“I want him to get better,” I said, stating the obvious.
“What else?”
“I want him to get what he wants.”
“Really? What if he wanted to kill you? Would you still want him to get what he wants?” Irv folded his napkin after finishing his sandwich.
I laughed. “Well, of course not.”
“Don’t laugh. A lot of our patients would like to kill us. The psychotic ones tell us so, which is why we can learn so much from them. The outpatients are much more artful at concealing the fact, even from themselves.”
“I really do not think that Mr. Sloan wants to kill me.”
“I agree with you. I don’t think he does, either. But since I promised to school you in cynicism, I just want you to be aware that there is murder in everyone’s heart, only most people have no clue it’s there. Most people are blissfully unaware of who they truly are, and they positively, absolutely, one hundred percent do not want to know the truth, which is probably all to the good. They’d be shocked if they ever saw themselves as they truly are. That’s why offering people the truth is such a perilous undertaking. It’s what makes being a psychiatrist dangerous, at least being a good one. People would rather kill than face up to who they are.”
“C’mon, Irv,” I said, “I really don’t think my patients want to kill me.”
“I know you don’t, and you are right about that. I just want you to know they have it in them, and even more importantly, I want you to know that you have it in you.”
I flashed back to how I attacked Uncle Unger’s hats. Irv could see that something had clicked. “That struck a chord?”
“Yes, yes it did.”
“So we now agree?”
“I guess so,” I said, surprised, if not shaken.
“Good. Then let’s come back to what you want from this patient. You want him to get better, you want him to get what he wants, as long as it’s not to kill you or hurt you, I assume. What else?”
Thinking of Uncle Unger’s hats had lowered my defenses. “I want him to like me.”
“Bravo!” Irv said. “Good for you! Exactement! That’s the really dangerous one. Especially for you. If you don’t mind my telling you, you are a real people-pleaser, which is fine, and much better than its opposite, except when you are doing psychotherapy. If all you want to do is make the patient like you and keep him happy, you will never allow him to feel enough pain to want to change and grow.”
“Yes,” I said. “You’re right about me. I’m actually working on that. I can be meaner than you think.”
“It’s not about being mean,” Irv said.
“I know, I know. I was just saying I’m not as much of a people-pleaser as I might seem. If I could go back to Mr. Sloan?”
“We never left him,” Irv said with a smile. “This work is all of a piece.” At that point, Irv pulled his knitting out of his doctor’s bag. He often knitted during supervision. “It helps me concentrate,” he’d explained when pulling his yarn and needles out the first time.
“His troubles might not just be because of depression,” I suggested. “I’m just learning about this thing called ADD over on the Children’s Unit. Do you know about it?”
“Why, do you think Mr. Sloan might have it? I thought it was just something hyper little boys had.”
“That’s the stereotype, but adults can have it, too. Do you know Paul Wender?”
“Yes!” Irv said enthusiastically. “He was a resident here. We were about the same age. He was one of the first residents to buck the tide of psychoanalysis back in the early sixties, which was the heyday for analysts. It took courage not to kowtow. But Paul didn’t kowtow to anyone. Used to drive his analytic supervisors nuts. But he was smart enough to get away with it. So is he writing about ADD?”
“Yes, he’s one of the people who’s saying it continues into adulthood, or that it can continue into adulthood,” I said.
“And you think Mr. Sloan might have it?”
“I was wondering about it. Of course, I’m just learning about it, so I am starting to see it everywhere. I actually think I have it myself!”
“But how could you? You’ve put up a stellar academic record. Doesn’t ADD mean you struggle in school?”
I loved how open-minded he was. This was what made MMHC so great. During my training, it was open season on truth. We could raise any idea, and our teachers would take it seriously. It was a great time to train, because everyone knew how awfully much we didn’t know.
Not to say there weren’t factions, but they weren’t vicious factions, as in the old days of Grete Bibring and the ominous Institute. The factions of our day got along, respected each other, and let us residents feast on the smorgasbord of their disagreements. You had the flamboyant Allan Hobson, one of only a few full professors at MMHC, a sleep researcher as well as an MMHC-trained general psychiatrist dosed heavily with Semrad, trying to take down Freud, especially his theories of dreams.
And then we had Joe Schildkraut, another full professor, father of the catecholamine theory of depression. In 1965 he wrote a classic paper published in the American Journal of Psychiatry, called the Green Journal because—guess why?—it had a green cover. In what became the journal’s most cited paper, Joe presented his findings that catecholamine dysfunction (especially norepinephrine) was strongly associated with major depression. That paper changed the direction of psychiatry, supporting the development of antidepressant medication and thus allowing the field to break free from the orthodoxies of strict Freudian psychoanalysis toward a broader, more eclectic approach, embodied in teachers such as Les Havens (“Try whatever you think will work”) and Doris Benaron (“Let the patient lead you”). Like Hobson, Schildkraut embraced psychodynamic thinking. Both men saw the issue not as either psychodynamic or biologic, but both/and.
And then you had the fast-talking pepperpot with the genius IQ Tom Gutheil, son of the famous psychoanalyst Emil Gutheil, holding up the best of the dynamic psychoanalytic approach. When one of my patients pulled out his own teeth after his mother’s suicide, ripped out the sinks and toilets, and flooded the inpatient ward, Tom suggested it was a manifestation of oral rage. “The porcelain of the sinks and toilets represented the enamel of his teeth, which he felt a rage to remove.”
To balance that, we had the ever-practical Bill Beuscher, who had been the faculty member in charge of the unit when I was a first-year resident. Bill was a psychiatrist’s psychiatrist. As I mentioned before, he just wanted to “cure people up.” Always dressed in a seersucker suit, he’d sit during rounds rolling his tie up and down as he listened. He seemed to be lost in thought, but he never missed a beat.
When I told him of Tom Gutheil’s interpretation of the reason my patient ripped out the toilets and sinks, Bill said sardonically, “Well, that may be true, and that may not be true, but in any case it’s useless.”
Irv fit in perfectly with the eclectic model. He had been psychoanalyzed by an idiosyncratic genius himself, Rolf Arvidson, and had become a psychoanalyst, but Irv was in no way wedded to the old rigid ways. Like Havens, Hobson, Benaron, and most of the others, he was more a humanist, a student of human nature, than a practitioner who fit into any category or mold.
Back to Mr. Sloan. Irv asked, “So you think he might have ADD? Why?” I could tell this was not a Socratic teaching question to which he had an answer already in mind, but a genuine request for information.
“Well, the hallmark of ADD—at least what I’ve been taught, I’m no expert, just a rookie you know, what Elsie Freeman taught us in her lecture—is that a person has trouble sustaining attention and getting organized. It becomes a struggle to get things done and done on time, and it’s not due to lack of motivation or brainpower. That’s Mr. Sloan, as far as I can see.”
“So what would the next step be?” Irv asked. “Don’t
they use Ritalin or something like that?”
“Yes, they do. I could refer him to Elsie Freeman’s clinic, but she only evaluates children. I’ll see if she’d make an exception, since now the experts are saying adults can have ADD.”
“Good. Why don’t you do that? Well, our time is up,” Irv said, putting down his knitting. “As always, it’s been a stimulating session. You are a talented doctor.”
“I bet you say that to all the residents,” I said, deflecting his praise but loving it nonetheless. Irv was always so validating. I knew for a fact that he did say this kind of thing to almost all the residents he supervised, but so what? I loved it anyway, and certainly did need it.
65.
“Where is her pain?” Dr. Benaron asked about Norah Devlin, the patient under discussion. Dr. Benaron and I were sitting for my supervisory session in the small office they gave her off the lobby of MMHC, a typically spare and barren MMHC office that Dr. Benaron instantly filled with her charismatic presence, as well as cigarette smoke.
Doris Menzer Benaron, one of the senior supervisors at MMHC, a grande dame of a woman, a Swiss psychoanalyst, had been close to Semrad. She was one of my favorite teachers because she was a little crazy herself, and she prized intuition, my favorite tool.
“I’m not sure,” I said of the patient. “She’s angry with her mother. But we are just getting to know each other.”
“She has an Irish name. Is she Catholic?” Dr. Benaron asked. “Always ask about religion. It matters a lot to many of our patients and doctors usually ignore it.”
“What religion are you?” I asked.
She took a drag on the cigarette that she was always smoking and then replied, “I’m Jewish, but I don’t believe in God.” She spoke with a German accent and delivered clipped phrases, not sentences, often separated by drags on a cigarette, followed by an exhale. “After the Holocaust, how can anyone believe in God?” Inhale, exhale. “Do you believe in God?”
“I think so,” I said. “I’m not sure.”
“That’s good. Watch out for the people who are sure. But never forget to ask your patients about religion and God. Freud hated religion so much that he drummed it out of psychiatry. That’s a big mistake because we have to look at whatever our patients are interested in. What we believe is irrelevant. We have to go to where they are. This patient of yours can probably talk about God much more easily than about her mother. So maybe begin by talking about God. See what she brings up. Then go there.”
“She just wants to talk about how angry she is at her mother for calling the police and having her brought to the hospital.”
“What else did she expect her mother to do?” she countered, sticking up for Norah Devlin’s mother like the true mother Dr. Benaron was. “You told me her daughter was breaking dishes and tearing her clothes off. Was her mother just supposed to watch?”
“I know,” I said. “She’s crazy. Well, not so much since we gave her the meds, but she sure was crazy when the police brought her in.”
“What do you think made her crazy?”
“I don’t know, but the meds made her better.”
“So you think it’s all about the meds?”
“I don’t want to think that. But it makes this job a lot simpler if you do think that way.”
“You want simple?” Dr. Benaron asked. “I don’t think you want simple. Do you want simple?”
“Actually, yes. But I know I can’t have simple and have the truth both together. I’m just looking at where this field is heading, that’s all.”
“Head, shmead, I’ll be dead. Meanwhile, we are where we are,” she went on, lighting another smoke. “My bet is that this is a Romeo and Juliet story, only she won’t let herself know it.”
“Why do you say that?”
“Just a hunch, from what you’ve told me about her. You get to be an old lady like me, there isn’t much you haven’t seen. Or lived.”
When she said “or lived,” I was quickly reminded that Dr. Benaron herself was bipolar and had had quite a few psychotic episodes. She knew from psychosis, as she would say.
“OK,” I said. “So should I ask her about Romeo?”
“No!” she snapped. “You must wait! You are so impatient. Has anyone told you that before? You are very impatient.” She tapped her finger on the desk as she said it.
“Yes, I know that.”
“Well, control yourself. It’s not good to be impatient doing this work. Wait. Norah Devlin will lead you where you need to go. She may talk crazy talk but try to follow it anyway. Do you know why I say that?”
“You’re trying to help me get inside the mind of the patient?”
“Correct!” Dr. Benaron crowed. “In psychosis, people think in primary process. Which can be crazy and crude. She may say fuck you, or even I want to fuck you, but don’t get scared. Civilization dresses us up. To understand our sickest patients, we have to be able to think in their language. It’s actually our language, too, but we don’t like to admit that. We like to think we’re above all that.”
“I can do that,” I said. “Primary process. It comes naturally to me. I like it.”
“Then you will do well with psychotic patients,” Dr. Benaron said, a pleased look on her bespectacled face, glasses, as usual, down her nose. “Do you know, I’ve been psychotic myself?”
“I’d heard that.”
“Were you afraid to tell me you knew it? Does it frighten you?”
“Well, it felt awkward, I have to admit. But it makes me trust you more. You know what it’s like. My dad was psychotic sometimes.”
When we first met, I had given Dr. Benaron a thumbnail of my history, but that was some time ago. I should have known she wouldn’t forget, at least not personal details.
“He never got over your mother,” she surprised me by saying. “He couldn’t accept losing her. He couldn’t accept her being with your stepfather. It drove him crazy.”
I was not going to cry, that was not what this felt like. It felt like someone was finally showing me what I’d been blinded to. It seemed so obvious. Why had I not seen it?
“If you’re going to understand crazy thinking, this is how to do it. Try to make sense of it. It’s not just all nonsense the way most people think it is. One last question. When your father threatened to hang himself that time you visited him in the hospital, why do you think he didn’t? Was he afraid of death?”
“God, no,” I said. “Dad wasn’t afraid of anything, except maybe insulin shock. He didn’t kill himself because he didn’t want to do that to us.”
“In other words,” she said, “it was love that saved him.” She paused to let me take in her words. She breathed in and out through her mouth a few times, as if she were airing herself out before changing the subject. “You were late today. Why?”
“Busy,” I said. “Too busy.”
“Nonsense!” she said. “Don’t be so busy you don’t make time to have your feelings. You could spend your whole life running away from your feelings, like most people do. I am going to train you to do otherwise. Be on time next week.” She exhaled hard, as if blowing me away, and buried her face in a book she was reading while I left the bare room she filled so well.
66.
Sitting beside Norah Devlin I remembered that Dr. Benaron had suggested I talk with her about religion, but I was curious to hear what she would bring up first, so I first just asked her how she was doing.
Norah was a twenty-two-year-old woman of Irish parents who’d been admitted to MMHC many times since her first admission at age sixteen. The diagnoses listed in her chart included borderline personality disorder, bipolar disorder, and histrionic personality disorder. She had ripped off her clothes at home and threatened to run out into the street. Her mother had called the police, who brought her to the hospital.
In our meeting the day before, all Norah had done was rail against her mother. In this meeting she appeared more composed. She’d put on makeup. (As an intern, I’d learned about
“the lipstick sign,” the first sign a female patient was getting better.) She’d also done up her long blond hair and was wearing a short print dress.
When I asked her how she was feeling, she lit a cigarette and said, “Yer new at this, aren’tcha? I like that. You won’t be as predictable after you’ve done this fer a while.”
“We start out predictable?”
“God, yes,” Norah said, rolling her eyes. “Soooo predictable. I’ve taught tons of ya.”
“Maybe that’s good, though—if we have a method, you know, like a predictable system for figuring out what’s going on, that’s good?”
“Now you sound like a priest,” Norah replied, absently undoing and redoing her ponytail. “That’s how they justify how predictable the services are. It’s liturgy. It’s tradition. It’s boring is what it is. They bore us into submission. Can ya believe those nuns sittin’ together sayin’ the rosary hour after hour after hour? Don’t they get a coffee break in there? You a Catholic?” Norah asked.
“No, but I know something about it. My favorite teacher in college was a devout Catholic.”
“Was he now? Didja go to a Catholic college?”
“No.”
“So, where’d ya go then?”
“Harvard.”
“Oh, well, aren’t you just fine and dandy. Did’ja learn anything there?”
“That teacher I mentioned. He was Irish. Well, his father was Irish. He grew up in Brooklyn. His dad was a bricklayer. He taught me a lot.”
Norah let out a loud laugh. “A bricklayer taught you a lot? That must have been a hoot!”
“No, no,” I said, flustered, “he taught me a lot.”
“Which he,” Norah asked, “the bricklayer or the bricklayer’s son?”
“The bricklayer’s son.” I could feel that I was blushing.
“Don’tcha know,” Norah replied, “that yer not supposed to be tellin’ me all this stuff about yerself? It’s quite out of bounds, ya know. Haven’t they taught’cha that yet?”
Because I Come from a Crazy Family Page 29