“Of course. It would not be OK if you hadn’t. And remember, I’m just a crazy old lady.”
“You’re anything but crazy, Dr. Benaron.”
“Talk more with Dr. Khantzian about all this, OK?”
I was taken aback. “How do you know I’m seeing him?”
“Because you told me!” Dr. Benaron said. “You don’t remember?”
“No, I don’t.”
“Well, very interesting. Talk to him about that, too!”
69.
At one of our unit’s biweekly Community Meetings, Adam, a lean and gaunt young patient, spoke up the moment the get-together was called to order by Professor Stein. Adam abruptly stood up and launched into a passage he knew by heart from the Bible:
Hear this, you that trample on the needy,
and bring to ruin the poor of the land,
saying, “When will the new moon be over
so that we may sell grain;
and the sabbath,
so that we may offer wheat for sale?
We will make the ephah small and the shekel great,
and practice deceit with false balances,
buying the poor for silver
and the needy for a pair of sandals,
and selling the sweepings of the wheat.”
The Lord has sworn by the pride of Jacob:
Surely I will never forget any of their deeds.
Adam delivered the passage with passion. He spoke the last line with a raised fist and a tremulous voice. When he finished he sat down, visibly worn out, while many of the patients gave him a round of applause.
We were all seated in the day room, where Community Meeting was always held. Before the meeting, the staff arranged the chairs in as wide an oval as possible, so everyone could see one another.
Marty, a middle-aged man of enormous girth, a very appealing wiseass, a serious atheist, and chronically psychotic, piped up after Adam spoke, saying, “I didn’t understand a word he said. Did anybody understand that?”
Francie, who had been in the outpatient group Jennifer and I ran but had to be admitted to the inpatient unit because she became suicidal, said, “Yes, I understood him. Adam was saying that even though people take advantage of us, we won’t be forgotten by God.”
“Bullshit,” Freddy said. “Bullshit” was all Freddy ever said, that and a few other stock phrases. He’d had a lobotomy decades ago, so he was more or less a broken record now. Still, I liked to imagine he timed his expostulations so that they made some kind of sense. Dr. Benaron was instilling in me the desire to decode crazy talk.
“Maybe it’s not bullshit,” I volunteered. We residents were encouraged to participate in Community Meeting to keep it moving along and to learn about the dynamics of a ward full of seriously mentally ill individuals. The idea behind it was that the community had its own underlying themes, a group unconscious, in a way.
“I don’t think it’s bullshit,” said Fritz, a man of German descent with bipolar disorder. He was deeply romantic, forever in unrequited love. “We’re forgotten by the rest of the world but there are people who love us.”
“Like who?” Now on meds, Kenny Luongo could participate meaningfully in Community Meeting and in life. Of course, the meds were not happy pills. “The world doesn’t give a shit about us.”
“That’s depressing,” Fritz said. “Can we change the subject?”
“Life is depressing, or are you just now catching on to that? Life totally sucks,” Marty said. “Just face it. Get used to it. Grow up, will you all?”
“You can be mean, Marty,” Francie said.
“I’m not mean, I’m just a fucking realist. I don’t get my hopes up so I can’t ever be hurt all that much. I expect nothing.”
“That, sir, is a grave mistake,” Rodney intoned. In his gold vest and tan sports jacket he graced the day room with sartorial splendor rarely seen in that setting. “My paper on division by zero was just rejected again. But I will get my hopes up once again and send the paper in to another journal. No doubt it will be rejected again and my hopes will be dashed once again. But my life would amount to nothing without hope. Hope is the key to happiness.”
“You are one crazy fuck,” Marty said.
“Aren’t we all in here?” Rodney said. “I just prefer my kind of crazy to yours.”
“I didn’t know we got to pick and choose,” Francie said. “I’d love to have your kind of crazy, Rodney. Can you teach it to me?”
At these gatherings, John Ratey invariably stood next to the fireplace. Now he said, “There’s a lot of sadness and anger in here today. Do you think it might be related to Linda’s being on vacation?” Head Nurse Linda was, of course, the closest thing to a mother the ward had.
“Fuck Linda,” said Stella, one of the younger patients. She had borderline personality disorder as well as a history of anorexia. Some of the characteristics of borderline personality disorder are moods that switch easily and quickly, lots of anger, insecure relationships, and intense, almost random attachments to people everywhere. Stella was very attached to Linda, so much so that she had made a suicide attempt the first day of Linda’s vacation. “Fuck Linda,” she repeated. “No, I really mean it, fuck Linda.” At that, she stood up and started pacing. She lit a cigarette. “I am so fucking tired of all this, I am just fucking tired of being fucked over every day.”
John Ratey intervened. “Stella, I am going to have to ask you to sit down, please.”
“Fuck you, asshole,” Stella said. “You can just go fuck yourself a hundred times with a big fucking dildo, OK?”
Two attendants went over to Stella. As they approached she said, “OK, OK, back off, I will sit down. OK. Just leave me the fuck alone.” The attendants returned to their seats.
“Ladies and gentlemen,” Professor Stein said, “what else is on people’s minds? Dr. Ratey suggests we may be angry and sad that Linda is away, and we are always grateful to hear from Dr. Ratey. Who else might want to speak up?”
In the brief silence that followed, I sensed people were relieved that Stella’s outburst hadn’t escalated into a full-blown assault.
Professor Stein jumped back in. “In that case, I have an announcement to make. Dr. Hallowell and I have decided to start a bridge group. All are welcome. We will meet here in the day room on an impromptu basis until we find the best time for all who want to play.”
“I love bridge,” Freddy said.
“Freddy, you can’t play bridge,” Professor Stein said.
“Bullshit,” Freddy said.
I hadn’t expected Professor Stein to make that announcement. Although he and I had discussed it, I had not yet gotten permission from anyone to start the group. But I couldn’t imagine anyone would object.
“I like bridge,” Adam said. “If I am still here, I will join.”
“Very good.” Professor Stein stroked his beard, his version of purring.
“What do you mean, if you’re still here?” Francie asked. Most of the patients were very tuned in to comings and goings and easily upset by others’ departures.
“I mean I don’t know how long I’ll be here,” Adam said. “I was put on this earth for a purpose and I need to find out what it is. Then I can leave.”
“Don’t hold your breath,” Marty said. “Nobody here is gonna tell you why you were put on this earth because no one fuckin’ knows.”
“Wouldn’t it be nice if someone did?” I suggested.
“Thank you for that comment,” Professor Stein said. “We always like it when you speak up, Dr. Hallowell.”
“What’s with you and Dr. Hallowell?” Marty asked. “First you’re playing bridge together and now you’re patting him on the back just for speaking one sentence. You two in love?”
Lots of people laughed, a rare event in Community Meeting. I laughed as well. Professor Stein stroked his beard.
70.
Tom Gutheil taught me that my role as therapist was that of a “hired co-investigator.” As I menti
oned earlier, he advocated an attitude of what he called “clinical dumbness,” whereby I should inquire, rather than jump to conclusions, and be as dumb as I could regarding the details of a patient’s life.
Another one of Tom Gutheil’s maxims was “A before T, and remember the fee.” A stood for administration, and T stood for therapy. And the fee established a boundary, that this was a professional service the patient was paying for. Administration was key, especially for a patient whose diagnosis was borderline personality disorder, in that the patient had to take responsibility to earn privileges before she could engage in therapy. Earning privileges was part of administration.
We couldn’t do therapy if a patient was in the midst of cutting her wrists. She’d have to stabilize first, through what are called administrative moves, like restricting her to the ward or even to a seclusion room, until she regained enough composure to be able to make use of a therapeutic conversation.
The learning curve was steep for me as a resident. Now that I had patients—real people put into my hands for help—I had to develop a systematic approach.
That’s why Tom Gutheil’s concise aphorisms were so helpful. They provided a guide, where I would otherwise have felt lost. My favorite of all of his many aphorisms is one I still quote often and use in my own life today: “Never worry alone.”
Yogi Berra said it’s impossible to hit and think at the same time. While not impossible, it’s not easy to do psychotherapy and think at the same time. If you try, you become wooden and shrinklike. Patients pick up on that in an instant.
I learned to be real, but not too real. Patients didn’t need to hear how my day was going, but if they asked, I tended to answer. I was learning to respect boundaries but also get close enough to form what’s called a therapeutic alliance.
But my awareness of others went deeper than mere politeness and set me apart. This is something I learned from all my patients and was rooted in how I grew up and with whom. What came naturally to me, what was obvious to me, was not at all natural or obvious to others. Others needed a script. If I used a script, it came off as stilted.
What I had to train was my tendency to connect too quickly, to get too close too fast. For example, one of my first paranoid patients, Joe, and I had a good session one day. He opened up about his fears and the anger that lay behind them, about the horrible mistreatment he’d received from his father, and how much he hated the food at the hospital because it was poisoned.
“Is there any connection between your belief that the food is poisoned and what a demon your father was?”
“What do you mean?” Joe asked.
“I just mean that maybe you never feel safe, no matter where you are, because of what your father did to you.”
Joe sat in silence, looking at me.
“To grow up like that, it must have left you with a feeling that there’s danger everywhere, even in the hospital food.”
Joe was listening, I could tell.
“So maybe if we talk about that, about how scared you felt as a child, maybe now you could realize that it’s over, that you don’t have to be so afraid.”
“Are you calling me a coward?” Joe asked.
“Just the opposite. I am telling you that you are one of the bravest men I’ve ever met. I mean that.” What he had endured—beatings, put-downs, daily insults, and what amounts to systematic torture—made it hard to believe he was alive today.
“Thanks,” Joe said. “I think that’s enough for today.”
Then I made my mistake. “How about if we meet again tomorrow?”
Joe was backing up, heading for the door, when he said “Sure,” and left.
That night he escaped from the hospital and took a bus to Santa Fe.
In my enthusiasm to connect, I got too close too fast. This makes anyone feel uncomfortable, but it makes a paranoid person panic. Joe panicked and bolted.
Like almost all of my talents, my intuition could be a blessing or a curse. With Joe, my having a “sixth sense,” a natural ability to see into people, led me to make a big mistake and cost me and Joe what progress we might have made.
I would never see Joe again. But he lives on in my memory and I owe him for his teaching me a bit about paranoia. It would take me a long time to fully learn the lesson that it was not enough to simply declare, “Please believe me. I mean you nothing but good. If you will trust me, I can promise you I will help you find a better life.” Gradually, the repeated failure of this tactic wore down my resolve to keep trying it. I grew into a more seasoned and realistic clinician. I came to accept and believe in the words of my old guide, Samuel Johnson: “The cure for the greatest part of human miseries is not radical, but palliative.”
If I hadn’t tried for the radical cure with Joe by naïvely believing I could gain his trust quickly, and instead opted for palliative by keeping a safe distance, one Joe could tolerate, I might have helped him instead of scaring the daylights out of him.
It remains one of the hardest lessons for me to learn, to settle for modest gains in my line of work.
71.
We residents at MMHC often worried too much that one of our patients would commit suicide. It made us defensive and overly protective of our patients. The former, illustrious head of the hospital, Jack Ewalt, the man whom Miles Shore replaced, was famous for saying that if there weren’t a few suicides every year, we weren’t doing our jobs right. He didn’t really mean it, he was being flippant, as was his wont, but he was trying to drive home the point that if we got too concerned about preventing suicide, we’d practice overly cautious medicine and would keep patients in the hospital too long, not giving them the chance to take responsibility for their own lives.
The term “regressive,” which mental hospitals are, means the environment takes care of responsibilities people normally have to take care of on their own. Semrad used to say, “Everyone wants to regress, we all do,” so that the job of the hospital and its staff is to oppose that common human urge as much as possible in order to promote the skills that allow for independent living. The guessing game—and despite statistics and research, it still did boil down to a guessing game—was to decide on the earliest possible date to discharge a given patient. There’s always a risk, but we tried to make it as calculated a risk as we could. Still, we residents feared we’d be blamed—implicitly or explicitly—if one of our patients actually committed suicide.
I was lucky in that none of my patients committed suicide while I was in training. My one patient who did commit suicide came to me early in my private practice. Hannah suffered from borderline personality disorder and was chronically suicidal. She was referred to me by her latest doctor who decided he had nothing more to offer her so it was time for a change, after her umpteenth admission and discharge from a local hospital.
In her midthirties when we had our first visit, she’d been in and out of hospitals since age sixteen. She was attractive still, with blond hair and some makeup, but she had the sunken eyes and pallid look of a person who’s suffered emotionally long and hard. I could feel how tired of life she’d become, and yet how tough and courageous she’d been to make it this far. Fighting off the wish to die is exhausting and demands enormous strength. Where she found it I have no idea. But find it she did, year after year after year of wanting to die.
In our first meeting in my tiny rented office in Harvard Square, the then famous Fifty-one Brattle Street, she said to me, “I can’t live like this any longer. I am not going to go back into the hospital ever again. I can’t live my life in and out of hospitals. I don’t want to and I can’t.” She was speaking as forcefully as she could.
“What’s our plan if you become suicidal?” I asked.
“It’s up to me to figure that out,” she said. “I’ve had the best doctors in the world, I’ve had every medication in God’s creation, I’ve had every form of therapy there is, and I just do not want to keep living like this. Would you?”
“No, I wouldn’t,” I replied. “W
hat does your family think?”
“There’s only my mother,” she said. “And she agrees with me.”
Hannah had made many horrific suicide attempts, mutilating herself in hideous ways that caused her enormous shame and distress. She’d been unable, despite the efforts of some great hospitals and doctors, to control herself. Today, perhaps dialectical behavioral therapy, or DBT, could have helped her, but we didn’t have that back then.
I made an agreement with Hannah and her mother that I would see her as an outpatient regularly. She came to my office twice a week, always on time, and we talked about her life, her hopes, her feelings. Her mother had invited her to live with her, but she preferred shelters. Her hope was to find a job and maybe a good man.
We made a compact that if she felt suicidal, she would contact me before hurting herself. We knew that the urge to hurt herself would pass if she could wait long enough, and my job was to help her wait.
“How can we be sure you will abide by our agreement?” I asked.
“I think we both know the answer to that question,” Hannah replied. “We can’t be sure. I’m addicted to suicide attempts and it is up to me to break the habit.”
“I hope you will try to let me help you,” I said.
“So do I,” Hannah replied.
One day I got a call from her mother telling me that Hannah had succeeded in taking her own life. I will never forget what the mother said to me. “Thank you, Doctor, for giving my daughter the chance to live life on her own terms. I think we all knew it would probably end this way, but thank you for giving her the chance at least to try to make a life she could enjoy.”
It haunts me that today we have better treatments for what Hannah struggled with than we did then. Maybe her life could have been saved.
But this is always my lament. It’s every healer’s lament. If only I could have done this, that, or the other thing, the bad outcome could have been averted. Like most doctors, I have a hard time accepting that terrible stuff happens, but sometimes neither I nor anyone else can prevent it, no matter what.
Because I Come from a Crazy Family Page 31