MADMAN - John R. Suler, Ph.D. - copyright 1995
Chapter 15 - Skeletons
On my way to the unit I again stopped by Marion's office. This time her door was open. She was writing at her desk, her back to me. Before announcing my presence I paused for a moment to look around the room, to soak in the atmosphere. I always loved her office. Unlike most staff members, she had not yielded to the institution's sterile and featureless surroundings. She had taken the tiny, squared-off, white-washed office the hospital assigned her and magically transformed it - two earthtone tapestries rather than blank walls, lamps with warm incandescent light in place of the harsh overhead fluorescent, shelves filled not with textbooks and endless streams of journals but family photographs, ceramics, dried flower and leaf arrangements - and an old wood desk, inherited from her grandfather, instead of those grotesque metallic monsters that loom over many offices like hungry gargoyles. Here all the scents of bureaucracy, authoritarianism, and medical science had been cleanly swept away. Her office was a haven. It was home."Come on in, Thomas," she said without turning around.
"How did you know it was me?" I replied, rather surprised.
She swiveled around in her chair and smiled. "Just a good guess. Are you O.K.? You look a little pale."
"I think I'm coming down with a cold, or something. Nothing serious, at least I hope not. I can't afford to get sick."
"Sit down and I'll make you some tea."
I settled down into the old stuffed chair at the side of her desk while she took two cups from the shelf, placed an herbal teabag into each, and filled them with hot water from a small electric teapot. Her movements were slow, smooth, thoughtful, as if preparing tea had become an accustomed but cherished ritual. The smell of orange mandarin spice filled the room. She reached towards me and placed the cup in my open hands. The warmth spread through my palms, my arms, into my body, draining all the tension out of me - more tension than I realized was there. I thought of being sick as a child, and my mother bringing me Lipton tea soften by milk and a dash of sugar.
"This place is getting to you, isn't it?" she asked.
"I guess I'm just having a bad day."
"It's hard to avoid bad days around here. Any more news about Elizabeth?"
"No. I guess I should call her husband to find out what happened, but I haven't had a chance. You know, I've been so busy today that I hardly thought about her at all - once or twice, I guess. That's pretty pathetic, isn't it? I really should call her husband, at least to express my condolence. I can't believe I didn't take time out to do it."
"Maybe you needed those distractions, needed some time away from thinking about her. Her dying might be affecting you much more than you realize."
"Do you think I discharged her too soon? I mean, getting run over by a mail truck! How many people die under the wheels of a mail truck? It could have been suicide. Her depression wasn't completely lifted when she left. Maybe my decision to discharge her was premature."
Marion's voice was firm. "The whole team decided on her discharge. You didn't make that decision alone. And we all agreed that she had improved significantly and was ready to go. You weren't responsible for the accident."
"I guess - but physically she still wasn't up to par when she left - her movements were still slow, and her speech. Maybe her reflexes weren't 100%. I should have ordered some more psychological testing before she left, just to be sure."
"Thomas, perhaps there were hundreds of others things we could have done - but you can't cover every contingency, you can't protect people from the inevitable."
"But it seems so unfair."
"It is unfair - to her, to you, to all of us. Life is unfair and there's nothing we can do to change that. You keep struggling against uncertainty and suffering, but there are limits to what you can do as a psychologist, and as a person. If there is any lesson to learn around here, that's it."
"How do you do it? You've worked at this hospital, in this profession, longer than anyone around here. Doesn't it get you depressed."
"It did, at first. Lots of people come into the mental health profession thinking they can help everyone, that they can cure even the worst schizophrenic. They may not say it, or even realize it consciously. In a year or two they find some patients coming back again and again, with the same problems. They realize that all they may be able to do is keep these people from getting worse. So, gradually, they lose their enthusiasm, or they burnout and move onto other jobs, even other professions. I know, I went through that phase. But then I discovered a kind of comfort in not expecting too much, a kind of peace in knowing that I do what I can. I learned that if even the very worst schizophrenic has a small chance at getting a tiny bit better, then that's worth the effort. And even if that patient doesn't get better at all, if all he or she can do is maintain their health where they are at, or at the very least experience a small measure of life's joy before they spin down once again into another episode of depression or psychosis - then that's O.K."
For a moment I was silent. "Do you know what happened today?... I'm almost afraid to talk about it, but I have to tell someone.... I've been seeing this borderline patient. She's quickly developing an erotic transference, as borderlines often do - and in the middle of the session today - well, she took off her clothes. I couldn't believe it. I know I must have made a mistake somewhere along the way for her to do that."
"Oh, it sounds like Cheryl."
I was temporarily stunned. How did she know? My brain raced. Marion and I were on the same inpatient team, but Cheryl was an outpatient. And Marion didn't know anything about my outpatients.
"You... you know Cheryl?"
"She's been a patient here for several years. She once sent flowers and a singing lovegram to a resident during morning report. You should have seen the look on the director's face. And another time, with another resident, she drove to his apartment house, sat on her car with a guitar, and serenaded him beneath his window."
"God, he must have been mortified."
"No more than you. Yes, Cheryl's done some very outrageous things. But I have to admit, what she did to you today takes the cake."
"When I tell Henry about it in supervision I just know what he's going to say: 'When a patient blatantly violates a boundary of therapy, you've been doing something wrong from the beginning.'"
"Oh I don't know about that. Henry's a very good psychologist, but he's still a bit new at dealing with these types of patients. You have to be flexible when you work with borderlines. And who knows, maybe what Cheryl did today was a good sign - after all, she was showing herself to you, allowing herself to be vulnerable. Isn't that was therapy is all about. Of course she did it in an inappropriate, primitive way. But that's what being borderline is all about. Maybe the sexual aspects of what she did are just on the surface of something much deeper, much more important."
Suddenly I felt more relaxed than I had all day, more at ease. "Sometimes it frightens me how quickly and strongly Cheryl has attached to me - how much she loves and hates me at the same time - how much she expects from me. What do I know? I'm just a dumb intern floundering around trying to figure out what the hell I'm doing. It's not fair to her. It's not fair to any of these borderlines who come to these teaching hospitals. They become extremely dependent on their therapists, they even begin to hope that there's a chance to get better. And what happens? At the end of the year, when our training is over, we leave. The institution recapitulates the very trauma that made people borderline in the first place - important people in their lives ignore their needs and abandon them. And then the patients are passed on to the next therapist in training and it starts all over again. The people you love are unpredictable, unreliable, they don't really care about you, they leave you. Maybe it's a great learning experience for the therapist but it's disaster for the patient. The fact that the institution doesn't recognize it - or doesn't try to change it - is a sign of its own sickness."
"You're right. It is a bad situation for those patients. But you know, I've seen them get better over the years anyhow. Even though interns and residents come and go, the patients often are seeing other therapists at the same time, usually social workers, who stay with them throughout the years. They do have some stability and continuity. It's funny that sometimes an intern or resident will make an interpretation to the patient, and the patient gets a lot better. So the therapist, eager to believe that he's having an effect, will attribute the progress to that interpretation and the latest theory that gave birth to it - when often it's not so much the interpretation but the cumulative effect of these patients getting the care and attention of these other therapists who continue to be there for them."
"It's funny," I said. "There's part of me that really wants to believe that I will make a difference in Cheryl's life, that I'm the one that will save her. And then there's a part of me that's afraid that I will make a mistake that will really hurt her. But worst of all, I worry that I won't have any effect on her, that all my work will be completely useless and meaningless."
"Tom, don't underestimate how important you are to a patient. I think we all have a tendency to do that, especially when we're not making any progress. I sometimes think that even when a patient complains and complains that we are doing nothing for them, unconsciously they feel the exact opposite, that we are having too much of an impact and it scares them. It scares them that they might become dependent on our help, that they might actually get better. And even when we make obvious mistakes - mistakes that temporarily hurt them - patients will forgive us as long as they sense that we care and are trying our best."
I stared at my cup of tea and nervously fingered the handle. I paused, deciding not to say anything, but then changed my mind. My voice cracked. "Sometimes, sometimes I wonder if I really do care about my patients."
Silence. It was excruciating. I was afraid to look up. I felt so conscious of her looking at me, looking through me. I shouldn't have said it. Now there was nowhere to hide.
Finally, she spoke, but her voice was surprisingly warm, reassuring. "For whom do you really doubt that you care?"
The question didn't make any sense - but it shot right to my core - and from that place I felt a sadness welling up, a lonely, abandoned sadness. The room shimmered and wavered as tears filled my eyes. I wanted to speak, to say something, anything, but there were no words in my throat - just that feeling mushrooming inside me.
I struggled to control it.
Without warning, a knock at the door pierced the silence. It startled me. My defenses sprung back into place, squashing my tears. They would have to wait until another time.
"Is Tom in there?" It was Fred's voice.
"Yeah," I gargled.
The door popped open. Fred stuck his head in. "Sorry to interrupt, but duty calls. Richard Mobin is here - your new patient."
"I'm on my way."
"Roger-dodger." Fred's head disappeared.
I placed my empty tea cup on Marion's desk. "Thanks," I said.
She smiled warmly. "Anytime, Tom."
The doorknob turned smoothly and the door to the unit opened with a clean, precise click. Phil had succeeded. As I stepped onto the unit I saw Carol coming towards me. She was buttoning up her coat.
"Boy, you're leaving late tonight," I said.
"Don't I know it. When I first became a nurse I knew that I'd be working hard. But I thought I'd be spending that time helping people, not writing endless reams of progress notes. I actually have to cut short the time I spend helping patients in order to write progress notes about how I helped them. Now that's a paradox, isn't it? And what bugs me is that hardly anyone ever reads the notes. I could spend that time writing a book."
"Why don't you turn those progress notes into a book?"
"Now that's an idea! I'll have to think about that. Anyhow, your new patient is here. He's over there with his mother, in the library cubicle."
"What's he like?"
Her eyes rolled. "He's a doozy. When Ron was doing the physical, and he tried to look down his throat, this guy got really agitated. He bit the tongue depressor in half, spit it out at Ron, and accused him of being a queer. He was practically shouting. Ron was really shaken by it."
I couldn't help but chuckle. Another chapter in the Escapades-of-Ronald to brighten my day. "I would say this guy's A LITTLE paranoid."
"Brilliant, Dr. Freud. Actually, there's something about this guy that gives me the creeps. He's an angry paranoid, obviously - not the quiet, stilted type. But that's not it. It's something else. I can't quite put my finger on it. I guess we'll leave that up to you."
"Thanks a lot."
"Anytime. Have fun." She headed for the door. I envied her. I wanted to go home too.
I rounded the curve of the apostrophe-shaped counter at the center of the unit - and caught my first glimpse of Richard Mobin and his Mom. Tucked inconspicuously into the corner of the library cubicle, wringing her hands, Mrs. Mobin looked fragile, weary, old before her time. Her winter coat, long out of style, was buttoned all the way up to her neck. It hung loosely, awkwardly on her tiny frame, as if she had shriveled up over the years. By comparison, her son, stuffed into the seat next to her, looked like a beached, bloated whale. I could envision him slumped over a kitchen table, staring into space, stuffing his face with cake and potato chips. Dark, shaggy hair that begged to be combed hung down over his sullen eyes. Beneath the stubbles of his unshaven beard his skin looked pasty white - as if he had lived in a cave, or at the bottom of the ocean, far from sunlight. He had taken one of the paperback books from the shelf and was flipping through it - not reading it, just flipping through it, persistently, forcibly, almost tearing the pages with his fat fingers, agitated by it, even angry at it for some reason only he understood - maybe simply because it was there. Carol was right. This guy gave me the creeps.
As I approached them, Mrs. Mobin jumped to her feet. Richard never looked up. "Are you the doctor?" she asked anxiously.
"I'm Dr. Holden. You must be Mrs. Mobin - and this must be Richard." I extended my hand to him. His eyes darted quickly at it and then back into the book. Ooops! A handshake. Wrong move for a paranoid. I dropped my arm to my side. "I'm the primary therapist for your son."
"Are you going to take him to the sanitarium and lock him up?"
"This is where Richard will be staying."
She looked around the unit, puzzled, skeptical. No doubt she expected St. Mary of Bethlehem, the first hospital for the insane in sixteenth century London - where patients were caged or chained to the wall, where they defecated on the floors and received beatings as a form of therapy. Londoners would visit the hospital to view the lunatics as a form of entertainment. It was as popular as the Tower of London and Westminster Abbey. The patients couldn't pronounce the full name of the hospital. So they simplified it and gave birth to a new word - "bedlam."
"THIS is the sanitarium?" she asked.
"We call it the Psychiatric Inpatient Unit. It's one of the wards of the hospital - like family medicine, pediatrics, obstetrics. Actually, this is one of the best psychiatric units in the state. Pretty nice looking, isn't it?"
"Yes..." She seemed impressed but still cautious. "Are you a psychiatrist?"
"I'm a psychologist, a psychology intern."
"Oh."
"Why don't we sit down for a while and talk... Tell me, what brings you to the hospital?" I looked from Mrs. Mobin to her son, hoping he would join in. He still ignored me and stared at the book, his beefy fingers still jerking through the pages.
"Richard hasn't been feelin' good lately. He hasn't been himself. I was worried about him. So I took him to Dr. George and he said it was psychological. He said I should commit him."
"Dr. George is your family doctor?"
"Yeah."
"What was happening to Richard that made Dr. George think it was psychological?"
"He's been real quiet, stayin' in his room almost all day. He won't go to school no more. Sometimes he locks the door and won't even come out for dinner."
"Why do you stay in your room, Richard?"
No answer.
"What do you do while you're in your room?"
Still no answer. I decided to persist, to test the limits with this guy. Maybe he was so withdrawn that he couldn't even hear me.
"Richard, what do you do while you're in your room?"
"Nothin'" he grunted without looking up.
Well, at least he could hear and respond. That was a start.
"He just sits there all day long," Mrs. Mobin explained. "He just sits there and stares at his fish tank. It scares me. He ain't never been like this before. He always did good in school. He was on the football team. Now he don't even shower or shave."
"When did you first notice that there was something wrong?"
"About a year ago - when he started cuttin' classes, and quit the football team. He's been goin' downhill ever since."
"Is that how it feels to you, Richard - like you're going downhill?"
He put his thumb in his mouth and chewed on it - hard. It made me nauseous.
"I guess you don't like the idea of being here. I wouldn't either."
He looked up at me for a brief moment and spit out a piece of his nail. Developing rapport with this guy was like snuggling up to a bed of razor blades. I decided to go for the big questions. I always felt uncomfortable asking them, but Fred and Dr. Stein would fry me in morning report if I didn't. I tried to be matter-of-fact about it, as if I was a well-seasoned psychiatrist who could ask about insanity like other people ask about the weather.
"Do you ever hear voices, Richard?"
He squirmed a bit but didn't look up from the book.
"Richard, I'd like to help you, and it would help me a lot if you could try to talk to me."
Mrs. Mobin started wringing her hands. "Richard, tell the doctor."
We waited. No response.
"Mrs. Mobin, has Richard said anything to you about hearing voices?"
She looked very uncomfortable. This was torture to the poor woman. "He thinks... he thinks his fish say things to him."
"Is that true, Richard?"
No response.
"What do they say to you?"
"None of your fuckin' business!" he grumbled between his teeth.
Oh, what a delight this patient was going to be. Why do I always seem to get stuck with them?
"Richard, don't talk like that to the doctor. He's trying to help."
"That's O.K., Mrs. Mobin. Richard, I know you don't like any of this and you probably don't trust me. That's understandable. Hopefully, in time you will. Is it O.K. with you that I ask your mother some more questions?"
He put his thumb into his mouth again.
"Has he told you anything else about what's bothering him? Is he worried or afraid of anything happening to him?"
She was taken aback, as if I had read her thoughts. Little did she know that any shrink in my shoes would ask the same questions.
"He... he thinks somebody is hunting him... men in raincoats."
Richard's fingers clenched on the book, tearing several pages from the binding. His lips tightened to a thin line. He was on the brink of rage. I decided to back off. I didn't need to know much more about his symptoms. It was a textbook case: auditory hallucinations, delusions of persecution, slow but steady deterioration in level of functioning with no apparent precipitating event. It was chronic schizophrenia. The fact that no apparent psychological or social stress triggered it suggested a biochemical problem - most likely an excess of a brain neurotransmitter, according to research, though no one really knows for sure.
Time to invite the skeletons out of the closet.
"Mrs. Mobin, can you think of anyone in your family or any relatives who had mental problems?"
"Well, my brother had a nervous breakdown once."
The infamous nervous breakdown. A layman's term that could mean anything - depression, psychosis, anxiety attacks. It was a concept left over from 19th century medicine which had just discovered the nervous system and attributed every possible malady to a defect in it.
"What do you know about his breakdown?"
"He had to go into the sanitarium."
"How long was he there?"
She lowered her eyes. "He died there, of consumption."
"I'm sorry." I waited a moment before continuing. "Can you think of anyone else who had a mental problem."
Still looking down, she again started wringing her hands. Richard too suddenly seemed more agitated. I hit on something.
"What are you thinking about?"
"I... I had a nervous breakdown too."
"Tell me what happened."
"I just couldn't keep up. I couldn't. I just wanted to stay in bed, and sleep. I felt so bad. They... they had to put me in the sanitarium too - just for a few weeks, until... until I didn't think about doing it no more."
"About killing yourself?"
Shame flushed across her face. "Yeah," she whispered.
"When did you have that depression?"
"It was after Richard was born."
The plot thickens. Maybe Richard's condition wasn't simply biochemical. What is it like being an infant with a depressed mother who disappears for several weeks after she delivers you into this strange world, who has no sparkle in her eyes and no smile on her face when she sees you - who has no energy to attend to your needs for being diapered, feed, touched, and loved? What is it like? Even as an adult you can't describe it. When it happened, you had not yet learned words to capture the experience - but in your body, in your guts and in your spirit, you carry that deprivation for a lifetime.
"Are you gonna give my son shock treatment?"
"No, we rarely do that here. Not for problems like Richard is having. Did you - " I stopped myself. If this poor woman did get shock treatment for her depression, I thought it best not to open up an old wound, especially in front of Richard, who at the moment needed her as an anchor. Her son was the patient now, and I needed some more of his history.
"Mrs. Mobin, what can you remember about Richard when he was growing up?"
"He was always a good boy - a bit quiet. He kept to himself mostly, didn't like the other kids. Just like his father - a loner. He always behaved proper - except..."
Richard's fingers tightened again.
Should I press her? I had to know. "Except what, Mrs. Mobin?"
"Except... except that time he found those baby birds."
Richard's hand closed into a fist, his fingers squirming against his palm.
"Go on, what about the birds?"
Watching Richard out of the corner of her eye, she continued cautiously, "Well... he found some baby birds in a nest. It fell to the ground durin' a storm. He tried to take care of them, feedin' them and all. But then one day he... well... he drown them."
Richard exploded. "I told you! I told you, goddamn it! They wouldn't take the food from me. They were dying on me!" His face was bright red. Veins popped out on his neck and forehead. It scared the hell out of me. I had to do something to diffuse his rage.
"I'm... I'm sure it was upsetting to you, Richard. I bet it was very upsetting. You did what you thought was best. But we don't have to talk about that now. Maybe some other time, O.K.?"
He leaned back into his chair, opened the book again, and continued flipping through the pages.
"I guess I don't have any more questions, Mrs. Mobin. Maybe this would be a good time for you to go home. Is there anything you'd like to ask me before you leave?"
She paused. "Will you take good care of him?" she said softly, lovingly.
I felt a bit sad for her. "Yeah, we'll take care of him."
She managed a brief smile. Slowly, she lifted herself up from the chair, lovingly placed her hand on her son's shoulder, and walked off the unit.