MADMAN - John R. Suler, Ph.D. - copyright 1995
Chapter 2 - Changing of the Guard
The psychiatric inpatient unit looked futuristic. The room was circular, with the exception of the entrance hallway that briefly disrupted its continuity, a short stem reaching to the outside world. The ten patient rooms - each containing two beds, a small bathroom, and a tinted window overlooking the countryside - were lined up around half the circumference. The remaining half consisted of a dining area and recreation lounge, a large room for group meetings, the two isolation rooms, and the director's office (one of the privileged few to have a window). A green carpeted walkway formed a ring that followed the contour of the circular wall. Dim track lights in the ceiling created a feeling of twilight, of being enclosed and contained. Two apostrophe-shaped counters were located in the middle of the unit, their outer surfaces paralleling the walls of the circumference, their inner surfaces perfectly positioned so that the bulbous portion of one counter fitted neatly into the tapering tail of the other, like two fish swimming gracefully around each other. One counter contained the nursing station, strategically located to allow the staff an unobstructed view of the entire unit. Windows looking into each patient's room also gave the staff visual access to activities inside, although patients were allowed to close their curtains at night and while dressing. The other counter contained two small cubicles for conducting therapy and psychological testing. They often were referred to as the "libraries" because their shelves were stacked with a collection of miscellaneous paperback books donated by the staff over the years. At the focus of the circular room, located between the two counters, in the very heart of the unit, was the slightly elevated Center Circle. If necessary, suicidal, obstreperous, and unpredictable psychotic patients could be seated there so the staff could keep an eye on them. A preliminary precaution. The last resort for dealing with a dangerous patient was Isolation - a locked room containing only a mattress. Most patients never required these features of the unit's clever architecture, although people suffering from agitated depression would take advantage of the unit's circular design by pacing around and around on the outer walkway. Manic patients liked to jog, sometimes fully attired in sneakers and sweat suits.
If, by magic, an unsuspecting citizen was swept off the streets and popped onto the unit, he might not even realize he was standing in a psychiatric ward. Very few psychiatrists wore the traditional physician's lab coat, and none of the nurses wore the standard white uniform. The patients seldom acted bizarrely, or became violent, or actively hallucinated, thanks to the miracles of modern medications. If the visitor spoke to the inhabitants, he would not suspect them mad. After several minutes conversing with a schizophrenic, he might feel uneasy about the unusual quality of his acquaintance's ideas or manners, but he probably would not realize the person was schizophrenic. Most people, even some mental health professionals, tend to underestimate psychopathology. It would take a while for our visitor to catch on; he might even mistake his surroundings for an innovative hotel for the eccentric.
Because the unit was a short-term facility, patients stayed only four to six weeks. Symptoms were treated swiftly, if possible. Patients who were severely disturbed, dangerously suicidal, or violent, were taken by ambulance to more secure institutions and involuntarily committed. They might stay there for months, years, or in the case of some schizophrenics, a lifetime. The financially distraught state institutions and the maximum security hospitals for the criminally insane were places you would rather not visit - and where you would dread to live. Simply mentioning these hospitals to unruly chronic patients, who knew the system inside and out, would snap them into compliance. To them, "We'll have to send you to Elmcrest" was like saying "We're sending you to the Black Hole of Calcutta." By contrast, the medical center was the luxury edition of medical treatment. So pleasing were the accommodations, so helpful and supportive were the staff, that many of the patients from poor neighborhoods balked when it was time for discharge. They never had it so good.
As I walked onto the unit I glanced at the clock. Three minutes to eight. Still enough time to skim through the charts to see how my patients fared through the night. I had learned one lesson on this internship: Always be prepared for morning report. Getting caught off guard without an explanation for setbacks in a patient's progress, even in your absence at night or on the weekend, was an embarrassing faux pas. Any reasonable explanation would do. Even all-purpose buzz words like "regression due to family conflict" or the handy "discharge anxiety" were better than saying "I don't know." That was the equivalent of saying "My brain is mush and I don't know what I'm doing." When confused, in doubt, or just plain ignorant, a doctor nevertheless must speak with unswerving conviction.
A tap on my shoulder pulled my attention out of the stack of progress notes. It was Marion. She smiled warmly - a spark of youth lighting up her aging, wrinkled face. "Sorry to interrupt. I just wanted to congratulate you for the fine job you did with Elizabeth. She made so much progress while she was here."
"She worked hard," I replied, "and really responded quickly to medications. And thanks to your work with the family, her husband finally realized how he contributed to her depression."
"True," she answered gently as she touched me on the arm, "but don't forget to give yourself a little credit too. See you inside." Hobbling, but in her strangely graceful way, she hurried off to the group room. Thank God for Marion. She was the old mother hen of the unit - warmhearted, caring, nurturing - attributes that did not exactly flourish among some of the other staff members. Somehow the training of social workers like Marion spared their humane, down-to-earth qualities, rather than effectively stamping them out as in the highly intellectualized education of the psychologist, or in the medically mechanistic shaping of the psychiatrist. In her forty years as a social worker, Marion had developed a different kind of knowledge, a quiet but hardy wisdom gained through a lifetime of work with the sick and poor.
I checked the time. Thirty seconds to 8:00. All the staff members were converging on the door to the group room, as if someone had tilted a chess board and all the pieces, big and small, were sliding toward one corner. I quickly popped the charts back into the rack and plunged towards the meeting, lest I be the one who was embarrassed by arriving late. Suspecting I was the last in, I quietly closed the door behind me and slipped into the nearest chair just as the head nurse began her report of the previous night's events. The usual stuff: A few patients requested some sleeping pills, Mr. Pinkton had an upset stomach, Mrs. Watts again was repetitively packing and unpacking her suitcase while sleepwalking. As I had deduced from the absence of new entries in the charts, my two patients had slept through the night without mishap. I felt spared, and grateful .
Safe, at least for the moment, I sat back and observed the ritual of morning report. During this transition from the night to day shift, the staff passed along information according to a strict protocol as orchestrated by Fred Cooling, the chief resident, also known as the "Chief." At the head of the room he sat tall, straight-backed, with squared off shoulders, like a true warrior presiding over the rituals. He deferred only to Dr. Stein, the director of the unit, who sat quietly off to the side, brushing and straightening his Armani ritual dress. He was the Really Big Chief, the keeper of the sacred bones of psychiatric wisdom. He also possessed more gold than anyone in the room.
I imagined an anthropologist from 24th century, sitting behind the one-way mirror, watching us, writing notes for a thesis about primitive tribal rites. The medicine men wear stethoscopes rather than bone necklaces, and they quote the Diagnostic and Statistical Manual of Mental Disorders rather than chant lyrics about spirits in the trees and sky.
And how could the ritual be complete without the caffeinated sacrament to wash away the sins of physical and mental lassitude? Some say the western world runs on oil, money, or the narcissistic quest for power. Wrong. The life blood, the source of all energy and motivation, is coffee. I looked around the lopsided circle of staff members. Everyone was holding a styrofoam cup. The Chief drank several quarts of the stuff each day. He had a cup pinned to each sleeve, and embossed into his favorite mug were the words "Caffeine Psychosis." No doubt the lining of his stomach looked like the inside of his mug - brown and crusty.
Not that I'm being critical. I too would have been quietly quaffing if I had had a few more minutes before morning report to suckle at the pot. How many businessmen and professionals would be thrown into a state of uncontrolled panic if coffee mysteriously vanished? Without its grounds, western civilization would collapse. And it's because the stuff is more than just a stimulant to gear-up the mind and body for work. Coffee is a social lubricant. Just think of all the conversing and laughing around the coffee pots of the world, or about the unspoken sense of community among people who imbibe together. Coffee means group cohesion. And let's not forget how it lends emotional support.When in doubt at work or in a uncomfortable social gathering, when you don't know what to do or say, when you're feeling insecure, you can always pause to take a sip; or simply stare into the cup, as though an answer might appear in the floating artificial creamer.
Coffee helps us feel complete.
Let me put it this way. Our early social training, when we are one or two years old, leads us to think we reside within the boundaries of our bodies. "Me" is everything from the skin and in. "Me" is mostly organic tissue with some mental and emotional stuff clinging to the inside. Rarely do we consider that our identity, both psychological and physical, projects outward beyond our mortal frame, how it is connected intimately to the material world around us. Coffee may seem a silly example, but it's not far off target. Consider your feelings about your very first car, or why you just can't bring yourself to throw away those old clothes, or the house where you grew up as a child, or why humans since the dawn of time have been possessed with producing artistic and scientific doodads that will live beyond them. The traditional psychoanalyst would say that such possessions are hypercathected with libidinal energy; more contemporary theorists would call them "selfobjects." The basic message is the same: We surround ourselves with satellites of our sense of self, each an external manifestation of some crucial aspect of who we are. We cling to them because they wield the power to make us feel more tangible, real, complete. They soothe our inner confusion as we struggle to stand on the shifting sands of our identity.
When I was in high school I had a small note pad. I used it to jot down homework assignments, ideas about class projects, and miscellaneous reminders to myself. One day I discovered it was gone! I turned my locker and every pocket inside out, my anxiety mounting with each passing minute that my search failed. I retraced my steps of that day, but to no avail. Ironically, only when I accepted that it was really, truly gone, forever, did my panic fade. Cold reason gave a helping hand, because, logically, it was no great tragedy. But on a deeper level there was a relentless feeling of loss. Something had been torn away, a piece of me had been squirted out of the universe, unexplainably. For other people it might have been a set of keys, a wallet, eyeglasses. In each case the anxiety about the lost object would signify the same predicament: a hole in identity that longs to be filled.
I forced my attention back to the meeting. One of the medical students was finishing up his sweaty explanation of why Mrs. Watts again was packing and unpacking her suitcase in the middle of the night. The Chief looked displeased with the student's rationale. He looked towards Dr. Stein, who was either bored or indifferent. He sat quietly on the outer edge of the circle of chairs, working at his fingernails with a gold file. Sensing that he was up the medical creek without a tongue depressor, the medical student looked down into his styrofoam cup. His two peers sitting next to him, similarly dressed in white shirts and ties, simultaneously raised their cups to their lips. I could swear their hands were shaking. Having admitted patients the day before, they knew they were next at bat.
"That's enough," the Chief grumbled, "let's talk to Mrs. Watts during rounds and find out what's going on." Fred set his stopwatch to zero and looked up. "The admission summaries have been running overtime. Let's keep them down to exactly three minutes." He paused his index finger over the start button and looked out across the room with an automated expression. "Rachel Finski was admitted yesterday."
The second medical student sprang to life, as if the Chief's announcement punched a button hidden somewhere on his chest. He straightened his spine and firmly gripped the clipboard on his lap. In a crisp, dry voice he read his admission summary.
"Rachel Finski is a 30 year old, single, white, unemployed female. She has had numerous hospitalizations in the past. This is her second hospitalization here. Her presenting complaints included feelings of depression and thoughts about suicide. Although suicidal ideation was present, no specific plan was mentioned. There was no homicidal ideation. Some of the vegetative signs of depression were hyposomnia, including early morning awakening, a decrease in concentration and memory, and a recent increase in appetite resulting in a slight weight gain. No significant psychomotor retardation or agitation was noticed. On the mental status exam the patient showed adequate remote and recent memory; judgment and abstraction were good; attention and concentration were somewhat impaired since the patient had difficulty with serial 7's but not multiplication or serial 3's; insight was fair; her salient thought content centered on suicide. The patient appeared to be above average in intelligence and she demonstrated considerable knowledge about psychiatry. A significant thought disorder was indicated by her thinking which was often tangential and circumstantial. Her ideas were bizarre and delusional. She believes her outpatient therapist was plotting to kill her and that she has been poisoned by contaminated tap water. The physical exam was unremarkable. Two years ago at the state hospital ..."
The budding psychiatrist. I imagined what it was like being in his shoes, being a medical student, learning the ropes of the medical world. The psychiatrist's training is quite different from a psychologist's. It focuses on biological treatments of mental disorders, especially psychopharmacology. For that reason, when you ask average laymen about the difference between a psychiatrist and a psychologist, the light bulb flashes and they answer, reflexively, "A psychiatrist can prescribe drugs." Very true. But lay people suffer from the mistaken notion that this privilege is icing on the cake for the psychiatrist, all other things being equal with the psychologist. The truth is that psychiatrists do not have the same expertise as psychologists plus more. Psychologists too have their own unique skills. Their training in graduate school emphasizes statistics and experimental research. They are the masters of diagnostic testing, including intelligence and personality tests. And unlike psychiatrists, they hold an academic degree, which means they have been doused with theories from a variety of fields in psychology - cognition, perception, memory, learning, personality, development, social processes, biopsychology - to name a few. They are expected to think like scholars. Perhaps that's why some mental health professionals perceive psychologists as overly intellectual and analytical. They're probably right.
Psychologists and psychiatrists often find themselves mired in professional competition with each other. Who is more qualified to do psychotherapy? One particularly sore spot concerns the coveted access to the secrets of psychoanalysis. Since the time of Freud, the psychiatric profession has jealously guarded this territory. Many orthodox analytic institutes, which are, supposedly, the most elite bastions for training in insight-oriented therapy, for many years refused to accept psychologists into their programs. Why? Because psychologists have no medical background. Other institutes have a more lenient philosophy and greater financial crunches: they welcome psychologists, and even social workers, into the fold. But the elitist medical analysts from the big-time schools consider these institutes watered-down imitations of the real thing. Only when pressured by the goliath American Psychological Association in an emotionally charged and historic lawsuit, did the orthodox institutes finally relent and open their doors.
Ironically, Freud, the founder of psychoanalysis and a physician himself, believed that of all the people seeking to be analysts, physicians are probably the least qualified. Why? Because they are too biologically-minded. Those with a liberal arts background, Freud suggested, can resonate better with the psychological, emotional, and interpersonal issues that make up psychoanalysis. Somehow many medical analysts have forgotten the great master's opinion. They have substituted other rationales. They claim that physicians, having worked with people who are ill and dying, better understand human suffering and loss. I wonder about that. If anything, their training may push their heads into the sand so they don't acknowledge suffering, especially death. Death is defeat, failure. And that rubs the M.D.'s omnipotent ego the wrong way. When Elizabeth Kubler-Ross, the renegade physician who pioneered the study of death and dying, asked her colleagues about patients who had passed away, some denied that anyone in their hospital died!
There's a parable about a peasant who pleaded with a guru to cure his grief over his wife's death. The guru agreed, but insisted that the man first find someone in the city who had not experienced the loss of a loved one. The man went from door to door, family to family, but every household had its own tales of death and bereavement. Finally, the peasant realized that he was a member of the universal community of human suffering. That was his cure.
That familiar demanding voice reached into my mental diatribe. I was just barely conscious of it: "Elizabeth Baso was discharged yesterday". Someone's elbow surreptitiously jabbed my forearm. A bolt of panic shot through me. "Elizabeth Baso was discharged yesterday," the Chief repeated, now with a distinct tone of irritation.
"Oh!," I crackled. Instinctively, I raised my hand to bring a coffee cup to my mouth. I needed to wash the frog - and the anxiety - down my throat. But there was nothing in my hand. I didn't have a cup of coffee! I cleared my throat and faked a confident voice.
"Elizabeth Baso was discharged yesterday after spending four weeks on the unit. Many of the vegetative signs of her depression were cleared by prozac during the hospitalization. Family therapy was successful in clarifying some of the family dynamics that contributed to her depression.Her follow-up treatment will be individual psychotherapy with Dr. Benjamin Levinson, a private psychiatrist in Flemington. Family therapy was strongly recommended and the patient was given a referral to the Carrington Clinic."
"Thank you," the Chief sighed. "The new admission today will be Richard Mobin. I'm assigning him to Dr. Holden. From what his parents told me on the phone, it sounds like a psychotic episode. He might be suicidal. His mother will be bringing him in sometime this evening." He paused to scan the room."Are there any other issues or questions?"
The staff looked at each other, then turned towards the director sitting in the back of the room, slightly outside the circle of chairs. He was clipping his nails and did not look up. There would be no pronouncements today.
"Right!," the chief resident tossed into the silence. He glanced at his watch and tried to suppress a smile of satisfaction. We were on time. "Let's get on with it."