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

by Montross, Christine

  Then, just as the stoplight ahead flips to red and the brother and sister in the story magically turn into Saint Bernards to better save a fallen French soldier from an avalanche, my son points out his window, toward the sky, and says, “Mama, what is that?”

  My gaze follows his finger, and high above us, aloft, is a murmuration of starlings in flight. I cannot begin to guess their number. There are hundreds. Or thousands. They form a dark and undulating cloud, now condensing, now diving, now rising like a black swirl of smoke above the low winter sun. As they shift and morph, their individual selves are lost in the mesmerizing glory of the whole.

  “Birds,” I say. “It’s birds,” my confused grammar reflecting the very question of the thing.

  “Birds?” my children repeat with a gasp, incredulous.

  “Look closely,” I tell them. “The cloud is made up of birds. They’re starlings, and they do this sometimes,” I say. “They do this kind of dance.”

  “Why?” my son asks, predictably.

  “I don’t know.” The light turns green, and as I start through the intersection, they protest immediately.

  “Mama! Mama, stop! We can’t see them if you do that!” So I pull over, into the driveway of a self-storage facility. I put the car in park. And while my children are otherwise captivated, I sneak my hand to the console and switch off the drone of the time-traveling sibling rescuers.

  For a long moment, we watch quietly as the birds, in unison, glide and fall and rise. Then my daughter: “Mama? Why does one of the birds turn?”

  “What do you mean?”

  “I mean, don’t you think that one bird starts it? Don’t you think that one bird decides they should go up instead of down or this way instead of that way, and it turns?” she asks me excitedly. “And then the other birds follow?”

  “Yes,” I say, “I do think that’s what happens.”

  “Why does one turn, then?” she asks me. “And why do the rest follow?” Yes, what small motion dictates where the group will go? What inclination strikes any single bird to lead?

  “It’s a good question,” I tell her. She is not satisfied with my answer.

  “But why, Mama? I really want to know.” Her voice trembles. She is tired from swimming, from keeping her little body afloat, and she is hungry for dinner, and the inadequacy of my response has led her to the cusp of tears.

  “I want to know, too, little bee,” I say.

  “So do I,” my son pipes in softly. We sit still, in silence, watching the birds. Eventually, one by one, they land on a power line. They squeeze in beside each other. The children shriek in delight, as if landing birds are a miracle. The starlings have transformed, yet again, into some new shape. The line of them stretches down the road as far as we can see.

  (EPILOGUE)

  Into the Fire, Into the Water

  And when they were come to the multitude, there came to him a certain man, kneeling down to him, and saying, Lord have mercy on my son: for he is a lunatick and sore vexed: for ofttimes he falleth into the fire, and oft into the water. And I brought him to thy disciples, and they could not cure him.

  —Matthew 17:14–16

  It’s been several years now since I was a resident, dreading blue buzzers, a lone doctor in the psych hospital in the dead of night. And the days of the consult service and Lauren’s desperate ingestions have begun to feel far away. Nonetheless, there have been countless occasions since then, in the midst of my current practice, when I have reminded myself of what I learned from Phyllis’s seizure, or from Anna’s courage in trusting her ability to care for her son, or from Joseph’s utterly despondent body that could not even respond to pain.

  The body mystifies. The mind more so. Witnessing their complex intersections—and the unbidden ways in which the two can catastrophically fray—can unmoor us. As doctors, who must dwell daily at the center of this unraveling, we can be tricked by action into feeling that our own human selves are less vulnerable. Yet action has the capacity to displace humanity, to disrupt connection, and, worse, to deceive. We reverse illness and cheat death often enough in the lives of our patients that we think we will surely be able to do so in our own. If we’re moving, then we can’t be caught. Yet our illusion of invulnerability is exactly that: an illusion. Like Colin’s euphoric sense of love emanating from everything, invulnerability is a chimera that portends an eventual fall.

  I can walk with you in this journey, Dr. LaFrance tells his patients, whose bodies reveal the psychological pain beneath. He offers an alternative to action’s false promises. I think often of how I left Joseph’s side when he could not answer my questions, unnerved as I was by the silence. I can sit with you in your pain, I wish I could go back and tell him. Or at least I am learning to.

  The poet Theodore Roethke endured episodes of severe depression throughout his life. His poem “In a Dark Time” reads in part:

  What’s madness but nobility of soul

  At odds with circumstance? The day’s on fire!

  I know the purity of pure despair,

  My shadow pinned against a sweating wall.

  That place among the rocks—is it a cave,

  Or winding path? The edge is what I have.

  As a psychiatrist, I hear the stories my patients tell me—noble souls that they are—and learn how their circumstances are at odds with their lives. They come to me bruised and upended, and when they do, the trajectories of their lives seem to them to be at best uncertain, at worst doomed. To fear that you might kill your own child, to scour your face with sandpaper, to swallow bedsprings—this is “the purity of pure despair.”

  If I am to abide with these patients, then I must accompany them to that place among the rocks, to the sweating wall. I must face with them the uncertainty of what lies beyond. I must stand at the edge with them and peer over into the fathomless depths. If I tell my patients, as I do, that this life can be a tolerable one, that they can face their fears and their traumas, their visions and voices, their misery, then I must look at what I am asking them to endure and I must look at it full in the face.

  One recent Saturday morning, I sat down with a patient named Elizabeth who had been admitted hours before in the middle of the night. At home she had found herself lying in bed beside her husband imagining ways she could die that would look as if her death had been an accident rather than a suicide.

  “I was so terrified by the thoughts,” she told me, “that I stood up, changed out of my nightgown, and drove myself here.” She paused and then continued. “Plenty of times recently, I’ve wondered why I’m still alive and whether it would be easier to die,” she explained, “but I’ve never thought of actually killing myself before. I mean, I love my family . . . and that would be unforgivable after all we’ve been through. It would devastate them.”

  “All you’ve been through?” I asked.

  Tears slipped out of the corners of Elizabeth’s eyes. Despite the tears, her voice remained steady and her expression was one of determined stoicism.

  “Eight months ago,” she began, “my son, Derek, was walking home from his high-school football game when he was hit and killed by a drunk driver. His sister had just started college, and she took it really badly. They were very close. We insisted she go back to campus. She’d worked so hard to get into her dream school and had been so happy there before . . .” Elizabeth trailed off. I waited for her to continue.

  “I think we all hoped she would find solace in getting back to her routine, but she’s really struggling with the death, and she says she feels so far from us. Then my husband lost his job—nothing he could have done about it, the company he’d been with for seventeen years was bought up and dismantled—but it was terrible timing. In this economy he’s had no luck finding something else. And then there’s my mom.” She laughed a self-conscious laugh through her tears. “Not to totally open up the floodgates, but my mother has dement
ia, and I’ve taken care of her for the last two years, and it’s gotten very hard lately. I don’t know.” Elizabeth paused. “My husband’s of the mind-set, you know, ‘Everything happens for a reason,’ and ‘We’ve all got our crosses to bear,’ and ‘You can’t move on if you dwell on things.’ But then I’ll find him, for long stretches every day, staring at the computer, not typing or anything, just staring . . .” She took a deep breath and looked at me. “I don’t even know what I’m talking about. Isn’t this pathetic?”

  “It sounds like you’re talking about loss,” I said softly.

  Elizabeth’s lips quivered, and her gaze turned to the crumpled tissue she was smoothing over and over again on the table between us. “A year ago?” she began. “A year ago I was dealing with my mom and I was joking to my friends about what a wreck I was going to be when my daughter moved away. I was happy for her, of course, but I knew I was going to miss her so much. You know what got me through it? My husband said to me one day, ‘Well, we had two years alone with her before Derek was born, and we loved those years. Now we’ll have two years alone with Derek before he goes away to school.’ That was the thing I held on to when we drove away from her dorm. That I’d have two precious years to really be with my son, and then . . .” She began to weep. “And then . . .”

  I sat across from Elizabeth while she could not speak. Behind us I could hear the unit’s washing machine begin to spin and a news program that some patients were watching on the television in the common area. I waited until she was ready to talk again. When she did, I listened.

  Eventually she said, her voice breaking, “Every minute when I wake up, I remember that Derek is dead. Every second of the day, I live with that knowledge—that loss—and I can’t do anything about it. My son is dead, and my daughter is distraught, and all my life I’ve done everything I could to make them happy and strong, and there’s not one thing I can do to change this for either of them. Not a thing.”

  Elizabeth wept. She turned the tissue over to its other side and began to smooth it in the other direction. “I miss my son,” she said. “That emptiness never leaves me, not for a minute. And my husband can’t talk about it, and my mother—who would have really been there for me—doesn’t know up from down. And now I’m in a psych hospital because I keep thinking that I’d like to go to sleep and never—” She choked a laugh and looked at me. “Well, Dr. Montross, I guess there’s no direction to go but up now, is there?”

  The French philosopher and Christian mystic Simone Weil wrote that to understand affliction one must accept our total human vulnerability. “I may lose at any moment,” she wrote, “through the play of circumstance over which I have no control, anything whatsoever I possess, including those things which are so intimately mine that I consider them as being myself.”

  Standing on the edge with my patients—abiding with them—means that I must harbor a true awareness that I, too, could lose my child through the play of circumstance over which I have no control. I could lose my home, my financial security, my safety. I could lose my mind. Any of us could.

  A wonderful psychotherapist said to me, in the wake of my having learned of my mother’s breast cancer, that we all live beneath a veil of invulnerability. For the most part, we act as if we and our loved ones will live forever. And then there are earthshaking moments in our lives—a diagnosis, an accident, some unforeseen catastrophe—when the veil is pulled back and we see with clarity that we are all in fact perched upon a precipice.

  Mental illness pierces the veil, and those who suffer from it dwell with their fragility in plain view. My role as a psychiatrist is not to try to repair the veil but to strengthen my patients so that they can live, so that they can suffer less, so that they can hope.

  Mary Weatherston is a psychologist who lives in Michigan. She is also a dear friend of mine. More than a decade ago, when I was trying to decide whether to go to medical school to become a psychiatrist, I called her to talk about her practice. I worried, I told her, about what it would be like to deal with my patients’ misery day in and day out. In retrospect, I think I was asking her how to abide with the suffering of others.

  Mary shares my love for northern Michigan and its lakes. Without thinking, she reached to that shared territory for a metaphor. “The patients we work with have fallen through the ice in the middle of a frozen lake,” she began. “My job—your job should you take this path—is to go out to them, to be with them on the thin ice, and to work with them to get them out of the frigid water.”

  I listened as she continued. “But you must know that if you go out to them on that thin ice, there’s a real danger that you’ll fall in, too. So if you go into this work, you’ve got to be anchored to the shore. You can reach out one hand to the person in the water,” she cautioned, “but your other hand needs to have a firm grip on the people and things that connect you to the shore. If you don’t, you lose your patients and you lose yourself.”

  • • •

  A short walk from the front door of our house is a path to the town beach. You turn the corner from a row of modest bungalows and Narragansett Bay suddenly appears at the end of a clearing, broad and commanding. The fateful names of its archipelago of islands seemingly chart settlers’ initial promise and eventual desolation: Goat and then Starvegoat; Prudence, Patience, Hope, and then Despair. We moved to this sleepy neighborhood in part because Deborah could never see the logic to do otherwise. “We live in the Ocean State,” she would say. “Why would we not live near the ocean?” The minute we moved in a year ago, she vowed that she would see the ocean every day, and she has stuck fast to her promise. If she finds herself in the evening without having been to the water’s edge, she will sneak down in the dark after the kids are in bed to breathe in the salt air. If it has been a daylong torrential downpour, she will slide behind the wheel of the car and drive the twenty seconds to the beach parking lot, where she will sit in the storm, windows cracked, and look out. I adore this about her. The insistence upon beauty and awe being a daily part of her life. The fixed principle of the thing.

  What makes her devotion to the sea even more endearing is that she both loves and fears water. We were barely grown-ups when we met, twenty-four, full of passion and silliness and righteous indignation. I drove her up to my family’s lake cottage in northern Michigan, where I discovered she could not swim, had never learned to do so. I taught her—floating, now face in the water and blowing bubbles, now gentle strokes and kicking all the while—and she loved it. But once she picked up her feet from the sandy bottom, she would giggle and tread water frantically, afraid to put them back down. Her abdominal muscles became rock hard that first summer. “Panic belly,” we laughed and called it, with the knowledge that our love, too, was new and deep and fearsome.

  Fourteen years later, her love has grown, both for me and for the water. Our marriage is now a calming refuge, a profound entity we seem to have known intimately our whole lives. The ocean scares her still.

  Recently Deborah took our borrowed kayak to paddle out into the bay. The water was calm, and she quickly ventured a fair distance from shore. I sat with the kids in the sand as they dug vast holes and collected hordes of vacant slipper shells. I watched Deborah’s silhouette glide across the horizon, her winged paddles, the narrow body of the boat. From time to time, she’d turn and wave, smiling. Soon the water twenty feet in front of her began to ripple and splash. The bluefish were running, and we knew it. Fishers had come to plant their rods in the shoreline’s firm sand, telling tales of bluefish so hungry they would beach themselves in an attempt to chase the glimmer of bait. In front of Deborah, the bluefish were after a group of sardinelike menhaden, churning the water into rough undulations that the fishers call a bluefish blitz. She looked back at me and pointed out to the choppy surface. I nodded. I had seen it, too. She paddled toward the shoal of fish, then floated, watching. The circle of churning water moved ten feet farther on. She paddled once or tw
ice to follow them. Suddenly I looked up to see her paddling frenetically backward. The shoal had turned toward her. They were utterly harmless, but she wanted no part of being in the midst of their feeding. Panic paddle. I could not help but laugh.

  We descend our neighborhood path not knowing how to interpret the signs the ocean offers us. One day a blanket of seaweed carpets the beach in a bright, luminescent green. The day before, tiny periwinkle snails were packed so densely on the ocean floor that it looked as if the sand were black. The day before that, the clear, calm shallows teemed with little hermit crabs that our children could clumsily catch, peer at, and let go. It baffles us, the ocean’s rash showiness, its endless capacity for grand gestures and flux. It baffles all the more because it is paired with nature’s silent and looming indifference. The still-feathered corpse of a seagull bobs on the incoming tide, head beneath the water and wings splayed across the surface. Or a wave tosses in a bleached vertebral column from what must have been a mighty fish. The wave recedes, the skeleton rolls on the shore, another wave washes over it.

  One day as we are walking down the path, our daughter, newly in kindergarten, turns and asks me to carry her. She is exhausted, and she is sweet, and I love that she still has these moments when closeness is her only desire. I lift her to me with a mock groan, to which she says, “Don’t say I’m too heavy, Mama. I never want to be too heavy for you to carry me.”

  “Someday you will be,” I say. “When you are as big as me, you will be too heavy for me to lift! Maybe then you will lift me.” She laughs at this unimaginable thought, then quiets.

  “How old will you be then, Mama?” she asks.

  “When you are as big as I am?”

  “When I am as old as you are now.” I do some quick math in my head.

  “When you are thirty-eight years old, I’ll be seventy,” I say.