Other than the sheer number of weddings, and the accumulating expense, what was the problem? The problem was that Mrs. Miller had never been invited to any of the ceremonies. None. Still, she fervently believed that she was an honored guest at every one of them, and if challenged could concoct an elaborate though ultimately nonsensical explanation for her attendance.
Her typical pattern was to arrive at the church or synagogue with some breathless flair just moments before the festivities began. She’d edge herself into a prime seat for the service, usually in the second or third row right behind the family, always on the bride’s side, center aisle, and she’d smile and wave at the other guests as though she knew them quite well.
She always cried during the vows.
On more than one occasion after the nuptials were complete she’d exited the church along with the bride’s family and joined the wedding party for the limousine ride to the reception.
Psychotherapists are trained to ask the question, “Why now?” Why is this man, or this woman, in my office seeking help today? Why didn’t she come in last week, or last month, or next week, or next month? The answer to the question yields what we like to call the “precipitating event.”
For the Millers the precipitating event for seeking psychological assistance was crystal clear. The previous weekend Mrs. Miller had, at the insistence of an irascible groom and an implacable bride, been removed from a festive wedding reception at the Hotel Boulderado by the police. The immediate precipitant for her removal was Mrs. Miller’s dubious decision to break into the celebratory dance between the newlyweds and politely, but firmly, demand her turn to waltz with the groom.
“Excuse me? I think you forgot your dance with me,” she’d said to him with a sad smile as she tapped the groom on the shoulder. “You’ll excuse us?” she’d added for the benefit of his befuddled bride. Then Mrs. Miller held up her silk-draped arms, waiting her turn to be swept away.
The groom, it turned out, was a Boulder sheriff’s deputy. Half the guests at the wedding were Boulder sheriff’s deputies. Not one of them recognized the woman in the yellow silk dress. Most importantly, the bride, who knew the detailed logistics of her wedding day as intimately as a chef knows the contents of his larder, didn’t recognize the woman in the yellow silk dress.
Later that day, at the police department across town, the authorities released Mrs. Miller to Mr. Miller’s custody with the strong suggestion that a mental health consultation might be in order.
Enter moi.
My appraisal?
Based on the brief history the Millers provided, Mrs. Miller’s descent into schizophrenia had been gradual. By history, I was guessing that she’d suffered her first psychotic break at around age twenty-three-she and her husband had celebrated their own wedding when she was twenty-two-and she had begun to display more intransigent symptoms of psychosis shortly after the birth of her daughter. Mrs. Miller was twenty-four at that time. The symptoms worsened once again after the birth of her son two years later. I suspected that over the intervening years her family had consistently minimized her growing list of eccentricities, and that the reclusive behavior she demonstrated-reclusive when she wasn’t attending weddings, that is-had been rationalized away one way or another. Evidence of her frank psychosis had, at times, been blatantly denied by everyone in her limited orbit.
The severe mental illness was Mrs. Miller’s. The conspiracy to pretend it didn’t exist, however, was most definitely a family affair. Her husband, Bill, was a nice guy. After five minutes in my office, I realized that he was a relentless cheerleader and a determined advocate for his wife. “Whatever I can do to help, I’ll do,” he said. “Anything.”
It was my unpleasant task to suggest to Mr. and Mrs. Miller that before they focused on issues in their marital relationship-perhaps-Mrs. Miller should seek some individual treatment for the difficulties she was having distinguishing things that were real from things that were not.
“Is it that bad? Really?” Mr. Miller said in mutual self-defense after I’d asked how he felt about what was going on in his marriage. “I love Rachel. In the grand scheme of things this is a small problem, right? I mean, we’re talking weddings. It’s not cancer. There are many, many times when she seems just fine.”
During my internship, while I was spending a rotation in an acute adult psychiatric inpatient unit, I had become extremely frustrated by one of my patients. He was a huge Samoan man, a schizophrenic whose communication abilities had devolved to the point where his speech consisted solely of multiple repetitions of a deeply baritone “hoho,” sometimes singly, more often tendered in multiple repetitions. Despite his severe psychopathology and his immense size-the man outweighed me by at least 200 pounds-he was congenial and cooperative. We would sit for brief one-to-one “psychotherapy” sessions a few times a week. Each meeting lasted five minutes, max. He would listen to me-I doubted at times that he comprehended the intended meaning of a single word I said-gesture in the air with his fat hands, and say, “Hoho, hoho,” occasionally interrupting my otherwise useless intervention, sometimes waiting politely until I was done.
Infrequently he would smile or open his eyes wide in apparent wonder. More often his face would yield no expression at all.
My Samoan patient was already receiving enough Haldol to sedate an elephant, yet his mystifying psychotic process seemed immune to my best, though admittedly inexperienced and ultimately ineffective, attempts to be helpful.
I confessed to my supervisor, who knew the situation well, that I felt incompetent to treat the man. The supervising psychiatrist said two things that have stuck with me ever since. First, he told me that there are some people who are better at being crazy than I will ever be at being therapeutic. The Samoan, he said, was my case in point.
Second, he told me that from a psychopathology perspective, some of our patients have cancer. He was speaking metaphorically, of course, but I still recalled his caution on those days that my clinical skills seemed hopelessly inadequate to contain the sometimes incorrigible forces of my patients’ mental illnesses.
I was tempted to share those pearls of wisdom with Bill Miller the day that he brought his wife into my office for evaluation. But I didn’t. His hope was too inspiring to behold. His desire to lift his wife up was too gratifying to witness. He didn’t want to believe that his wife had the mental health equivalent of cancer. I feared that indeed she might, but I wasn’t ready to believe it either. That’s how powerful his hope was.
Despite the fact that I thought I’d pulled just enough of my punches to allow Mr. Miller’s hope to stay afloat, my ultimate assessment that day, and my verbalized prescription for further care, sucked all the oxygen out of the room.
Every last molecule.
In contrast to bipolar disease, which at its heart is a disorder of mood, schizophrenia is a disorder of thought, of perception. Schizophrenic thinking results in a myriad of cognitive symptoms. Hallucinations, delusions, and paranoia are the most common. In a schizophrenic’s world, what most of us consider orderly thought begins to deteriorate, and cognition becomes subject to interferences from beyond the confines of usual perception. The process that results appears to an outsider to be bizarre, tangential, repetitive, or oddly referential.
An extreme example was my Samoan’s baffling chorus of hohos. But in a schizophrenic’s brain the variety of ways that faulty neuro-chemistry can cause thinking to deteriorate is large. In severe cases the outcomes are almost universally tragic.
The problem that was most apparent to me during my brief appraisal of Mrs. Miller was the extent of her delusional thinking-specifically her irrational belief that she had been a special invitee to all those weddings. Although the nature of the invitations remained her secret during our interview, that was where I focused my attention as I presented my suggestions to the Millers.
Mr. Miller seemed somewhat relieved by my prescription for additional help. For him, it represented an injection of helium that might pro
vide enough lift to keep his airship of hope afloat. But Mrs. Miller resisted my recommendation and argued and bargained and then bargained some more. I couldn’t follow her train of thought as she tried to explain the imperative she felt about attending the weddings. The truth was that her thinking more closely resembled a corral of bumper cars driven by preadolescents than anything like a metaphorical train.
She wept for a good five minutes before she ultimately relented to my suggestion and to her husband’s gentle prodding. She only relented, I was certain, because of her husband’s insistent kindness and his repeated promises that he’d be beside her no matter what, and because I’d managed to make it clear on that day that my resolve was a more than decent match for her thought disorder.
The fear in her eyes when she realized what was about to happen next was as poignant a thing as I had witnessed in my office in a long, long time. She rested her head on her husband’s shoulder and with eyes full of fat tears she said, “Okay, okay. Okay, okay. Okay, okay. Okay, okay.”
He said, “I’m here. I’m here. I’m here.”
I’d been doing clinical work for too long to consider entertaining the clinical delusion that the fact that Mrs. Miller had relented for that moment meant that the road ahead would be smooth.
“No more weddings?” she’d asked me incredulously only a moment after her four pairs of okays had trumped her husband’s three-of-a-kind of I’m here. “Oh Willy, does this mean no more weddings?”
Bill-Willy-looked at me for direction.
I said, “Yes, I’m afraid it does.”
With a despair that I could feel all the way to my toes, she lamented, “What will they do? Oh, what will they do?”
What I saw in her eyes wasn’t concern, it was fear. She hadn’t said, “What will I do?” She had said, “What will they do?” She was worried about “them.”
I wondered, of course, who “they” were. The brides and grooms with whom she hadn’t yet celebrated? Or perhaps-and I knew this was more likely-the speakers of the voices that I suspected were whispering or shouting wicked nuptial imperatives into her ears.
I didn’t know. Nor did I suspect that she would tell me. Not that day.
While the Millers were sitting in my office I’d already acknowledged to myself that I wasn’t the best-equipped mental health professional in town to help Mrs. Miller with her individual treatment. I explained my rationale to the Millers, and with their consent I picked up the phone and called Mary Black-the same psychiatrist who was sharing offices with Hannah Grant before Hannah’s death-and asked if she could do an urgent emergency assessment.
I’d chosen a psychiatrist to assist Mrs. Miller because I knew that the initial phases of Mrs. Miller’s treatment, and likely the long-term progression of her care as well, would involve the shuffling and management of antipsychotic medications, and in Colorado the provision of those pharmaceuticals was the domain of the medical profession. I’d chosen Mary Black as a psychiatrist for Mrs. Miller not only because Mary was good, but also because she was relatively new in town and she was still hungry for fresh patients. I didn’t think it was advisable for the Millers to wait weeks to see a psychiatrist and begin treatment.
Mary graciously agreed to evaluate Mrs. Miller later that afternoon. Mr. Miller had driven his wife the few blocks over to Mary’s office directly from mine, and I’d never seen the Millers together again.
Months later, at a summer party at a mutual friend’s house, Mary Black had suggested to me-“You know that woman you referred to me? The wedding woman?”-that Mrs. Miller’s care had quickly degenerated into a carousel of poor treatment compliance, failed trials of conventional drugs and the newer atypical antipsychotic compounds, and repeated short-term, stabilizing, acute hospitalizations.
The wedding planners and pastors and ministers and rabbis in town knew all about Mrs. Miller by then. Ushers at virtually every wedding ceremony in the county carried an eight-by-ten glossy of her in full nuptial regalia, and after six months of futile mental health treatment she was being turned away at some church or synagogue door almost every Saturday.
It was precisely the kind of outcome that I had feared.
When she was done telling me the story of what had happened to Mrs. Miller, Mary Black told me one other thing. She said, “I don’t think my husband would stand by me the way her husband has. It’s inspiring. Truly inspiring. The things he’s done for her…”
Mary’s eyes told me something else: that she knew that I knew that I owed her one.
Bill Miller came back to see me a little over a year later. It was the January right after the horrid Christmas when Boulder ’s little blond beauty queen had been discovered dead in the basement of her home. Bill and I met for only a few minutes, maybe fifteen. He’d asked for the time so that he could thank me for my help with Rachel. I’d told him, honestly, that I didn’t think I’d done much.
Although he’d suggested that his wife’s treatment with Mary Black hadn’t gone particularly well-and explained that he and Rachel were temporarily separated-he didn’t offer any details and I didn’t ask for any. We talked briefly about the Christmas-night murder of the little girl, how hard it was for his kids, and he asked me whether I’d noticed the story in the Camera about the young orthodontist who’d been hit by a car and killed a few days before Christmas near Chatauqua. I said I had. He told me he’d witnessed the accident, and I wondered briefly if that traumatic experience was why he had come back in to see me.
But as I waited for Bill to irrigate that wound, he moved on. He said that he and the kids were coping, and he made a particular point of explaining how well things were going for him at work-he’d just been promoted to a post he’d always coveted-as though he wanted to emphasize for me that, despite his wife’s illness and his marital problems, his family life hadn’t totally fallen apart.
Although I don’t really remember, it wouldn’t surprise me to learn that I had ended the session with some generalized offer of future help, something like, “Let me know if there’s anything I can do.”
He’d probably said, “Thank you,” and that had been that.
11
“The girl was anxious about the holidays? And she misses her mother? That’s what the session she had with Hannah was about? That’s it?” I said to Diane.
“No. No, that’s not all of it,” Diane said. “Come on, I’m doing this from memory. It was no big deal at the time. I didn’t take any notes. The whole consultation lasted five minutes, maybe. God, I should write things down. I just should.”
“What do you remember?”
“The girl told Hannah that her mother has a severe mental illness and had left Boulder years ago. The girl doesn’t talk to her much, misses her. Hannah was speculating about the mother having bipolar disorder or schizophrenia, but she didn’t really have enough information. She was worried about the girl developing symptoms.”
I wanted to tell Diane that I already knew the details. I wanted to tell her about all the weddings that Mrs. Miller attended, about the lovely bonnets and the QVC gifts, and about the delusions, and the voices. I wanted to tell her that at the time I did my eval that I thought Hannah was right about the schizophrenia, wrong about the bipolar disorder.
Instead I said, “You can’t tell anybody, Diane. You can only divulge the fact that this girl saw Hannah for psychotherapy if you have reason to suspect that there has been, or is likely to be, child abuse. Otherwise the privilege holds.”
“But she can’t seek care without a parent’s permission until she’s fifteen.”
“You’re sure about that?” I asked.
“Yes.”
Diane was often sure about things that turned out not to be true, but I suspected she was right about that one. “Even if it’s true, I don’t know whether that would abrogate her privilege.”
“But it might.”
“You’re not even sure it was really Mallory. You’d have to violate privilege even to be certain. God knows there woul
d be lawyers involved, and once there are lawyers involved, anything can happen. Either way, the privilege won’t evaporate today. If they started litigating this tomorrow you wouldn’t have an answer before next year’s aspen season. You know lawyers better than I do.”
“What do you mean? You’re married to one, while I”-she paused for effect-“am married to a Mediterranean god.”
I decided not to take that detour with her.
“What if she’s dead?” Diane asked.
Shit. “Diane, do you know that she’s-”
“No, no, I don’t. I don’t. But if she were, if that was determined, I was wondering if I could-”
“No, you couldn’t-confidentiality survives death. Well, actually you’d have to tell her parents if they asked, because they would probably have control of her estate, which includes all her medical records, but-”
“Why would they ask? If they didn’t know she’d been in treatment, why would they ask?”
“Exactly.”
Diane and I had been partners longer than Lauren and I had been married. I wasn’t surprised that we were finishing each other’s thoughts. But the ping-pong nature of the conversation we were having felt awkward to me. Why? I suspected that each of us was in possession of some information that we weren’t sure how to handle, information we didn’t want to keep to ourselves, but information we weren’t at all sure we were permitted to share.
“The girl also told Hannah-”
“Wait, I want to do this face-to-face. I have a patient late this afternoon at the office. I’ll come downtown. You available?”
She sighed. “I was just about to head out to the after-Christmas sales on the Mall. Things are going to get really picked over if I don’t get down there soon.”
After-Christmas shopping on the Pearl Street Mall? I would have preferred to be strapped into a chair and serenaded by The Captain and Tennille.
Missing Persons Page 6