Falling Into the Fire: A Psychiatrist's Encounters with the Mind in Crisis

by Montross, Christine

  Colin’s emergency certification form cited this exact sort of “grave disability”: “Patient not eating, not drinking adequate fluids. Delusional. Periods of bizarre posturing. Twenty-pound weight loss in six to eight weeks.” And with that he was in.

  It’s not a stretch to say that simply by virtue of his position, Colin was powerless to a certain degree. We had the legal right to keep him inpatient for ten days. As long as he did not take any of the medications we offered, we had little grounds upon which to discharge him. Colin was caught in a circle of logic. If he continued to deny that he had a mental illness that was in need of treatment, we could continue to assert that his insight and judgment were impaired and that therefore we had cause to hold him against his will.

  It’s easy in a situation such as Colin’s to regard the institution of psychiatry as the authoritarian legacy of One Flew Over the Cuckoo’s Nest, to think of psychiatrists as cartoonish egomaniacs who thrive on their ability to take away the agency of others or who leave no room for divinity, for difference. Indeed, many patients who are admitted to my care reveal deep-seated fears that they will be stripped of their rights, medicated against their will, restrained, or sedated into the “Thorazine shuffle.”

  Yet in reality, psychiatrists, like their colleagues who go into various other medical specialties, have a specific desire to help people heal and to treat them humanely in that pursuit. And so behind all the posturing and joking about our patients’ admission photographs is the hope that we really are honing our diagnostic abilities and, in doing so, might be able to lead a patient out of the throes of depression or the haunted hallways of psychosis.

  When involuntary hospitalizations come into play, it is almost always because study after study demonstrates that we, as doctors, are terrible at predicting which of our patients—be they depressed or delusional—will kill themselves. And in a profession whose every aim is to heal and help, the assurance of protection often feels more precious than the preservation of autonomy. Without a crystal ball to show us which patients will be safe and which will not, we must rely on our clinical intuition. We meet patients for perhaps thirty minutes and must in that period of time determine whether they are telling us the truth, whether they are able to follow a safety plan, or whether they are impulsive enough—or disturbed enough—to jump off a bridge or push a bystander in front of a train. We have no medical imaging that will tell us the answer, no blood test to shore up our clinical intuition.

  It may be tempting to lament the medication of a patient’s heightened sense of connectedness or of his new spiritual fervor. Indeed, Colin’s case was even more ambiguous because he seemed to be more elated than distressed, yet the costs and dangers associated with psychosis are tragically real. The famed author and neurologist Oliver Sacks points out the perilous allure of madness in discussing what he calls euphoric “hyperstates” or states of “ominous extravagance.” Sacks cautions us against ignoring—or, worse, celebrating—symptoms that seem to be happy but are a departure from the person’s typical self: “The paradox of an illness which can present as wellness—as a wonderful feeling of health and well-being, and only later reveal its malignant potentials—is one of the chimeras, tricks and ironies of nature.” In fact, a heightened “good” feeling—what George Eliot evocatively called “dangerous wellness”—can itself be a signal of sickness to come, more terrible still for its deception. Most of us cannot exist over time in a sustained state of exultation. More often a high is a sign of a crash to come. Many of the healthiest among us are familiar with that truth. For the mentally ill, the danger can be even more pronounced. The poet Robert Lowell, who endured both the excoriating manias and the debilitating depressions of bipolar illness, wrote, “If we see a light at the end of the tunnel, / it’s the light of an oncoming train.”

  The persistent One Flew Over the Cuckoo’s Nest mythology about psychiatry has doctors forcibly overmedicating and overtreating people who require neither medication nor treatment. The opposite is true. Far more often the most ill patients struggle to obtain access to treatment and to maintain their adherence to medication. Far more often the mentally ill among us are undertreated. And the consequences of untreated mental illness—from financial ruin and homelessness to violence and suicide—can be truly grave.

  I had seen countless patients who had endured the consequences and indignities of untreated mania or psychosis. A man who suddenly felt an intense connection to nature left his home to live in the woods off Interstate 95. He drank daily from a pond of stagnant water, inducing diarrheal illness and eventually life-threatening dehydration. A manic businessman in a euphoric frenzy gambled away his company’s assets and his family’s entire savings before he acquiesced to treatment. A paranoid young man stabbed and mildly injured an elderly stranger for no apparent reason. When the police arrested him at his home, the man’s girlfriend cautioned them to be careful, explaining that he had recently been psychotic and dangerous. Once at the station, the man grabbed the gun of the interrogating officer, fired multiple times, killing the officer, and then jumped out a third-story window. Once apprehended, the man was beaten by the police until he was disfigured and was eventually sentenced to two consecutive life terms in prison.

  I felt that if Colin were left untreated, he would be at risk for these kinds of dire consequences, yet he did not share my concern. Eventually he began taking our medicine, but only after I asked him why, if he loved all that was of the world, he would not also love these small blue pills. I’m not sure how much of his agreement had to do with my colluding argument and how much with his growing understanding that going along with the treatment plan would speed up his discharge.

  After a day or two of the antipsychotics, the nursing notes reflect a subtle change: “Patient more lucid; states he is communicating more clearly. Patient also states he no longer feels the love he once did from inanimate objects. The patient is less grandiose, more subdued. Sometimes seems confused.”

  Colin did not say that he was sad in the wake of his euphoria, but he certainly did not seem particularly relieved either. He was sleeping regularly, and eating, and consistently urinating in the bathroom, signs that were reassuring to me. Still, the ecstasy that he seemed to have been feeling was less prominent, if it was there at all. One morning as we met, Colin stared at the floor, solemn. “I’m not sure about this existence,” he said to me. “Are you?”

  I gave him the nebulous diagnosis of Psychosis, Not Otherwise Specified. I knew that Colin could be in a psychotic episode within the context of bipolar illness, but I worried he might be in the early stages of schizophrenia. His age fit both possible diagnoses. Half of all cases of bipolar illness emerge before the age of twenty-five; the average age of onset of schizophrenia for men is the early to mid-twenties. Bipolar disorder is more than twice as prevalent in the United States as schizophrenia, affecting 2.6 percent of the adult population as opposed to 1.1 percent, so by numbers alone it was more likely for a young man like Colin to be afflicted with bipolar disorder. Still, schizophrenia’s fearsome specter loomed in my mind, partially because Colin’s symptoms strongly matched the description for the illness’s onset and partially because the consequences of such a diagnosis—unlike those of bipolar disorder—had such catastrophic implications.

  The DSM describes the first indications of schizophrenic illness—the “prodromal phase”—as a “slow and gradual development of a variety of signs and symptoms (e.g., social withdrawal, loss of interest in school or work, deterioration in hygiene and grooming, unusual behavior, outbursts of anger).” I thought of Colin’s on-and-off metalwork, the initial ER description of him as “malodorous . . . unshaven,” his girlfriend’s concern, his parents’ characterization of this period of time as a kind of spiritual awakening. “Family members may find this behavior difficult to interpret,” the DSM continues, and may “assume that the person is ‘going through a phase.’”

  If Colin was in the mid
st of this prodromal phase, then his disorganized behavior—walking backward, urinating in Coke bottles—would continue and his odd beliefs about file cabinets emanating love would bloom into full-fledged delusions. He might begin to hear voices. He might withdraw from his girlfriend and his family. He might become paranoid instead of euphoric. But he would need to have these symptoms for six months in order to meet criteria for schizophrenia. Only time would clarify whether my fears were true.

  • • •

  Around the time I treated Colin, I traveled to an interdisciplinary conference on the theme of madness in order to present a paper. My fellow presenters were an eclectic and interesting group. I was one of only three psychiatrists. There were a handful of psychologists and social workers, but the majority of speakers and attendees were academics in the humanities who studied madness in literature, or in linguistics, or from a sociological perspective, or within history. There were also a small number of patients at the conference who self-identified as “survivors” of mental illness or as “mental-health consumers,” a term meant to empower patients by placing them in a reciprocal position with mental-health providers. Within their ranks were representatives of Mad Pride and people from the antipsychiatry movement.

  In general, I like a good discussion, and there were plenty over the course of this three-day conference. As at any such event, several of the presentations were fascinating and several were dull. Yet as the conference progressed, I found myself first becoming dubious about some of the papers presented, and then finally I began to get downright furious.

  It seemed that particularly among university academicians, the urge to render madness romantic was strong. Isn’t it so, they argued, that passion is a kind of madness? That it is from a crazed and not-commonly-understood state that the most vivid and intensely human art emerges? One after another they began to list, in an attempt to bolster this argument, a chorus of names that have come to symbolize both great torment and great genius: Woolf, they said, Dante, Sexton, Lowell. With each pronouncement the group seemed to gain confidence and momentum: Shelley, Plath, van Gogh. It struck me as a marching song. A cadence by which the Mad Pride parade could rally and process: Handel, Hemingway, Munch!

  I was uneasy and annoyed with the emphasis on the creative benefits of madness, though admittedly, at times, those who are stricken by their visions or mercurial moods seem to be the strongest proponents of this perspective. And who knows better than they? “As an experience,” Virginia Woolf once declared, “madness is terrific I can assure you, and not to be sniffed at; and in its lava I still find most of the things I write about.” To top it off, the allure of Woolf’s “madness” is not limited to this heady state of inspiration but also offers a kind of rare and perfect productivity. “It shoots out of one everything shaped, final,” she professed, “not in mere driblets, as sanity does.”

  It is both difficult to argue against the authority of such a statement and difficult to want to argue against the truth of it. There is something magical about an idea like this, and something explanatory. We, in our hemmed-in and earthbound states of sanity, could never compose the Messiah or Mrs. Dalloway, and this mad state of genius is, in a proverbial nutshell, why not.

  In addition, we cannot overlook the fact that the creation exists: Schumann’s Cello Concerto in A Minor soars; van Gogh’s furored strokes swirl auras around so many stars. Perhaps it is the awe that these rarest works of art inspire that leads the academic discussion of madness step by step into the dangerous and alluring eddy of romanticization. The scholarly treatment of madness may not march in celebration through the streets, but in some ways the disciplined restraint implied by the language of critical theory that emerged over and over again at this conference is at best a façade over just this kind of salutation. At worst it is an example of how distant the ivory tower can be from the reality of human experience. “No one works better out of anguish at all,” James Baldwin said; “that’s an incredible literary conceit.”

  When a terrified psychotic patient nails the doors and windows of her house closed and huddles in a corner for days without food or sleep, believing that she is being hunted by alien agents, it is difficult to characterize her schizophrenia as a “fragmentation of the capitalist self,” as I once heard the illness described at an academic conference. When I watch a friend of mine lose her job, her spouse, and finally her will to live to the relentless claws of a bottomless depression, I cannot take seriously the theoretical classification of those who suffer from mental illness as “existential radicals.”

  My mind churns with example after example of lunacy’s cruel baseness: A woman with postpartum psychosis who repeatedly and viciously attacks her husband because she believes he is trying to kill their baby and spends the first two weeks of her daughter’s life in a locked psychiatric ward racked with devastating delusions that her baby is in grave danger. An elderly man so gripped with dementia that he shouts and swings at any person who approaches him, fearing that the aides who change his clothes are trying to molest him and that the daughter he does not recognize is trying to feed him poisoned food. A middle-aged banker who believes he must save the world and secretly hoards his feces in a drawer in a hospital’s intensive psychiatric unit. It is certainly possible that, like the good and bad sides of the same coin, whatever predisposes the famously mad artists to mental illness also predisposes them to beauty, artistic vision, or creative drive. But even if it is madness that makes possible extraordinary creation, how much ingenuity and productivity are short-circuited by that same madness? How much potential greatness is lost in insanity’s dark corners?

  Mental illness, and the suffering it carries with it, can consume a person’s whole life. And when it does, there is no room for the most basic pleasures, let alone the loftiest of great creations. For my patients, madness is not a political statement. More important, it is something by which hardly any of my patients would choose to be burdened. For those of us who are fortunate enough to be comparatively sane, it is abhorrent to stand in celebration of Woolf’s madness. It did, after all, cost her her life. It is audacious and self-serving of us to celebrate mental illness as rebellious and brave, as productive and ingenious, as the mythical, maniacal muse of our artists and writers. At the end of so many of these stories, we are left with their masterpieces. But the lives behind the stories are riddled with suffering and hospitalization and suicide. The brilliant psychologist and author Kay Redfield Jamison has said that bipolar disorder—an illness from which she herself suffers—“benefits mankind at the expense of the individual.” Who are we, exactly, to say that it is worth it? Even if madness is at the root of some of the world’s great creations, it is hard to imagine that if someone asked each of us to live an entire life of suffering in the service of the arts, we would agree to do so. Even if we might choose such altruism, it’s unlikely we would allow anyone else to make that decision for us.

  And as fiercely as we hold to this romantic argument of greatness arising from madness, are we sure we have it right? What if the opposite is true in the cases we cite of van Gogh and Schumann and all their sad, mad peers? What if the greatness of these artists existed not because of the madness but in spite of it? Might our mad creators—and the countless other artists who were so afflicted—have blossomed even more fully if not hindered by depression or haunted by psychosis? For Plath and Woolf and Sexton and others who prematurely ended their own lives, we must also consider what further genius might have arisen over the full course of their lost years.

  There is no glamour in my patients’ lives. For the vast majority of them, their daily existence holds much misery, and no romance. And yet it is comforting to those of us gifted with sanity to believe that there might be some redeeming, glorious, even magical aspect to the deadening, punitive force of madness. There is surely veracity in Woolf’s description of her mental illness, but in celebration of the “lava” of madness and its fantastic by-products it is all
too convenient to lose sight of the story’s end: a brilliant woman loading her overcoat pockets with stones and stepping into the river Ouse to die.

  “I feel certain that I am going mad again,” Woolf wrote to her husband in her suicide note. “I feel we can’t go through another of those terrible times. And I shan’t recover this time. I begin to hear voices, and I can’t concentrate. So I am doing what seems the best thing to do. . . . I can’t fight any longer. . . . You see I can’t even write this properly. I can’t read. . . . Everything has gone from me but the certainty of your goodness.”

  • • •

  In the earliest moment of morning, a mockingbird perches on our neighbor’s redbud tree and lets fly trill after trill, fluted note after fluted note. Our bedroom windows have been cracked open all night just enough to let in the mossy chill of spring. In the daytime I find this bird’s song to be an enthralling spectacle of flawless copies: now a pewee, now the mewing squawk of a catbird, now the whistle of a wren. I could listen all day. Sometimes I do. But at 4:00 A.M., burrowed beneath an old quilt and half aware that my young children have managed, for nine hours, to sleep soundly without a single “Mama,” the mockingbird’s call grates at me, all painful awakening and incessant noise. If I could throw a pillow out the window and hit my mark, I’d have to say I would.

  It’s a reminder. The thing stays the same. It’s our vantage point that changes. Humanity has a fickle vein in which something can be sometimes loved and sometimes hated. What is it that tilts the balance?

  I used to sleep until midday if I could. When I was a teenager, a twenty-year-old even, visiting my grandparents on a school vacation, my grandfather would cackle to see me rise, all rose-cheeked and rumpled. “Eleven o’clock!” he’d crow. “Oh, to sleep like that.”

  My grandmother, a great bird-watcher, would’ve been up hours and hours earlier to see what she could see. I wish I’d asked her, before she died, what it was about birds that she loved so much. She was, however, prejudicial in her admiration. She’d tell me a hundred times about tramping through the northern Michigan jack pine forests with her friend Kay to catch a lucky glimpse of a Kirtland’s warbler. Then, just as often, she’d disparage “those horrible starlings,” or curse the invasive merganser ducks that infiltrated our Michigan lake.