MADMAN - John R. Suler, Ph.D. - copyright 1995
Chapter 5 - Patients
"Mr. Tennostein is looking for you." Marion stepped into the elevator as I stepped out. I grabbed the rubber bumpers to prevent the doors from closing."Is he O.K?"
"Irritable as usual, but O.K. He says you forgot his appointment."
"I told him we would meet at 9:30."
"How many times did you tell him?"
We laughed, but Marion was mostly serious. The elevator doors tugged at my hand, reminding me to expedite this conversation. "Did you call the Motor Vehicle Bureau?"
"Yes," Marion sighed, "and finally got connected to someone in the central office. He said the only way to revoke his license is to get a signed statement from a psychiatrist saying he is psychologically incompetent to drive."
"So be it. Do you want to tell him?" I crossed my fingers. Another tug from the dutiful doors.
"I think you should," she said and then smiled. "Be gentle, but straightforward with him. You can do it."
I let go of the doors and she disappeared. "Well, this is going to be an interesting morning," I informed the elevator.While I hurried towards the unit I rehearsed what I would say to Mr. Tennostein. Head first, I crashed directly into the metal doors. They were locked!
"What the hell is going on?!" I muttered. No sooner did I start rubbing my insulted cranium than the doors opened. His bulbous belly, which strained at the buttons of his green work shirt and spilled over his belt, preceded him. It was our janitor Phil, screwdriver in hand. "I'm working on this cursed lock again," he announced in his typically jovial manner. "I'll spend the rest of my life trying to fix it."
"So I've noticed," I replied, still massaging my bump.
"Sorry about that! But look at it this way," he said paternally. "This here lock is just trying to do you a favor. Its trying to protect you from what's inside, trying to prevent you from going in there and worrying yourself too much. It's a form of stress management. He hesitated a moment, then laughed uproariously from his belly. He always got a kick out of himself. I, on the other hand, was not amused.
"Only joking," he continued once he calmed down. He held the door open for me. "Go ahead. Better you than me."
The unit hummed with activity. Nurses were dispensing the morning medications and some of the patients were assembling for a group therapy session. Across the room a thin, hunched-over man waved feebly at me. I circled around the periphery of the unit as he walked towards me with his awkward, prancing gait. We intercepted at one of the library cubicles, and I motioned for him to sit down.
"Hi Mr. Tennostein."
"I've been looking for you," he said tensely. "I thought you forgot our appointment."
He looked terrible. He was only 56 but you could easily mistake him for 90. The shaking in his hands had spread to his arms and head. His sunken face and darkened eye sockets reminded me of pictures of concentration camp survivors. This man was no victim of war, but he had lived through his own nightmarish holocaust.
"I thought I said we would meet at 9:30," I said gently, hoping to prod his memory.
"You said 9:15," he replied angrily. "What, do you think I'm stupid or something?"
This wasn't going to be easy. I knew I must help him see how serious his problem was, but denial is a very powerful and stubborn defense mechanism, especially in patients with organic brain syndromes. Usually you can't attack the defense directly - that only intensifies it. But you sometimes can work your way around it.
"No, of course you're not stupid. In fact, just the opposite is true. Perhaps it was my mistake. I'm sorry for the confusion, and I don't blame you for being annoyed."
Some of the indignation drained from his face. He settled back into his chair. A serious breach in rapport had been averted, at least for the moment.
"How about we continue with what we were talking about yesterday," I continued, "about why you came to this hospital."
He immediately dove into the explanation I had heard many times before. But for him it was still fresh. "I didn't want to come here. My wife made me. She's the one who said I was doing strange things. I know I wasn't. I'd be just fine if people would let me be."
"Hm, like what kind of strange things did your wife talk about - I mean you ex-wife. You were divorced what - about five months ago?"
His eyes rapidly shifted back and forth in his head as his mind tried to connect to the forgotten fact that his wife had left him. "Yeah... yeah, about five months," he said hesitantly.
"Right. And what kind of strange things did she say you were doing?"
"I never hurt her. I never laid a hand on her. I've always tried to be a good husband. I never wanted to hurt anyone! I mean, sometimes I would break things when I was drinking, but that was an accident -"
"Yeah," I injected quickly, "I'm glad you mentioned that. It's interesting that you would accidentally break things when you were drinking - like the alcohol was affecting your balance, or your coordination, or maybe even the way you were seeing things. It reminds me of what you were telling me yesterday - about what would happen after you were drinking, when you were drying out. About the spells."
"I don't know what you're talking about."
"Remember, we were sitting over there by the nurses station, and you told me how sometimes your thinking gets a little bit confused, how you lose track of things?"
"You mean when I get squirrely?"
"That's right. When you get squirrely."
Finally a loophole! A way past his defenses! But will it close up too fast? Be sure to stay close to his line of thought. Use his language. "Tell me again," I continued, "what is it like when you get squirrely."
"I feel squirrely, I ... I'm not sure. Things seem confusing. Like that time I was looking for my car in that parking lot, at the mall. Damn if I couldn't find it. Those lots are so damn big. I still think someone moved it on me, probably some teenagers playing a practical joke."
"You were walking around the parking lot for an hour or so, weren't you?"
"Oh, it couldn't have been that long." He squinted while he paused to think. "I sat down for a while to rest. I read my book for a while too."
A confabulation. He was fishing for answers to fill in the gaps in his memory. I decided to push ahead. "You know, Mr. Tennostein, this is exactly the kind of thing that I think we need to help you with - these episodes when you get squirrely, like at the mall. We've got to make sure that you don't go through things like that anymore. I'm sure it was very confusing and upsetting for you. We've got to find out what's causing these episodes and how to control them. We have to make sure that you're safe."
"Yeah, I guess ..."
"Some people have spells like that. And like you they don't always remember what happens during them. In fact, I think you might have had a spell the first night you were here, two nights ago. You were probably a little nervous about being in the hospital, and that triggered it. You walked around and around the unit, then you went into the shower with all your clothes on. Do you remember that?"
"I remember ... being wet ..." A realization slowly dawned on him. He looked troubled. This could be the turning point.
"How often do you think these spells happen?"
"I don't know. It's only happened once or twice. Damned if I know what causes it. Probably just fatigue. I'll be fine if I could just get out of here and get a good night's sleep in my own bed."
"We're not sure either about what's causing the spells. We were talking about it on team yesterday. Dr. Sheikh said he thinks it's something called transient global amnesia. Basically, that means that every once in a while the brain, well, sort of short circuits. Sometimes being excited or under stress will trigger it. The person may become disoriented and not know what he is doing. It might be caused by some deterioration in brain tissue."
"You mean my brain is rotting?"
"I wouldn't quite put it that way. Sometimes the damage is very subtle. We need to do some tests to find out."
"What kind of tests?" he asked skeptically.
"We want to call in a neurologist for a consult. He'll do an exam on you. We'd also like to have a Catscan done. That's sort of like a multiple series of x-rays that - "
"I know what a Catscan is," he interjected. His hands were shaking again. "How could something like this happen? What does that to the brain?"
"No one knows for sure. It may be in part hereditary. The brain ages in everyone. It atrophies as you get older. In some families the aging occurs faster."
"I remember my father being senile," he said thoughtfully, "he'd say the damnest things."
"That makes sense. And now that we know you're having these spells, we should do everything we can to control and even prevent them. For instance, since your drinking seems to trigger them, one thing we can do is to help you to stop drinking. I would recommend that you join AA."
"Forget it," he said angrily, "My drinking isn't any big problem, and besides, I can quit myself."
"It's not easy to quit yourself. Maybe you've even tried before, so you know how hard it is." I paused. His defenses were springing back, but I felt I had to go further. He had come far in this session. I may not have another chance like this.
"But we can talk about that later," I continued. "There's something else I wanted to talk to you about. Something more immediately important. These spells you've been having could be dangerous. What if you had one when you were driving your car? You've already had a few fender-benders. You were lucky. Or what if you had a spell while you were cooking. You might accidentally burn yourself or start a fire. You need to live in a place where people can help you, where it's safe for you. There are some homes you could move to. We can - "
"No! I'm not going to any home," he replied loudly. "Never!"
"Then maybe we can help you find someone to cook for you, or deliver hot food to your house. If you continue to live at home, it would be a good idea to have a visiting nurse to stop in each day to check on you, or even a nurse to live with you, if you can afford it."
"I don't need a baby-sitter. I can handle my own life."
"Of course! There are lots of things you can still handle. There will be lots of things in your life that won't change at all - that will even get better, like learning how to control those spells. But you'll need help with some things. And there are some things you shouldn't be doing because we have to make sure you're safe. As I said, it's dangerous for you to drive. I know it will take some adjusting of your life, but you should stop driving."
"Forget it! How would I get around, go to the bank, or to the stores to buy... No, I won't give up driving. Absolutely not!" The tremors in his hands set off a twitching in my guts. I forced myself to continue.
"You can have friends drive you, or take buses, or taxis. We'll help you make arrangements. Who knows, you might enjoy not having to worry about a car anymore."
Desperation gripped his face. His eyes were tense and red. "No! I won't give up my car. I can drive. I can! And I don't even have to cook. My wife can cook for me. She's cooked for me all these years, and cleaned, and did the shopping. I don't need no busses or nursemaids!"
For a brief moment, I almost believed him. I wanted to believe him. Then our eyes connected and our hearts sank together as the unfortunate truth sprang forward into our minds. He had no wife - not anymore.
He leaned forward, burying his face into his hands, and began to cry.
"Why! Why has this happened?" he moaned.
I rose from my chair to put my hand on his shoulder. "We'll do everything we can to help you," I said softly in an attempt to soothe him. "Maybe we'll call your ex-wife - maybe she can help in some way." A sadness welled up inside me. Beneath it there was this strange squirmy feeling.
"Please leave me alone," he replied as his crying subsided.
"I think it would be good for us to talk some more."
"I just want to go to my room. Please, let me be alone."
Without looking at me he struggled to his feet and hobbled away. For a moment I considered following him, then decided against it. Still fluttering inside, I walked to the nursing station and pulled down his chart. As I thumbed through the pages I thought about the question that issued from his pain. Why did this happen to you, Mr. Tennostein? I don't know. Heredity, parenting, socialization, historical context, biological and psychological predispositions, karma - who can explain the complex set of factors that intersect at one point to shape a person's fate? Do we ever really make a choice, or are we simply pushed around by a bewildering mishmash of causes and effects.
"How did it go?" Marion asked as she entered the nursing station. She was holding a cup of tea.
"I finally got through to Tennostein. You know, it's very ironic. Ten years ago this guy was doing O.K. Sure, he had a problem with drinking and he surely wasn't the most psychologically healthy man on earth. But he was married, he had a good job as a teacher, and as far as we can tell from the psychological testing, he used to be well above average in intelligence. Then fate catches up to him. He's forced to retire early because he's not performing as well as he used to. The bottle becomes his new occupation. He grows depressed and angry and abusive, his wife leaves him - finally it's obvious that his brains are falling apart. No longer is he well above average in intelligence. All of a sudden he's hanging onto life by a thread, too terrified to see how terrified he is. Then I come along. Mr. Young Psychologist. And what do I do? I try to get him to confront that terror. I try to get him to see how his mind and his life are failing."
"Don't think of it as failing," Marion said. "He sank so deep into his problems that he couldn't pull himself out. He needs help. He needs you. And your job is to help him see his situation as clearly as he can without overwhelming him - and to give him some hope, something worth living for. "
"But is there hope, or is that just our defense to help US feel better? What can we really do for this poor guy? He's on the decline.We can't reverse the damage in his brain. If anything, it will get worse. Who know's, it could be Alzheimer's."
"Then you must help him confront what's ahead," she answered calmly. "Confront it with strength and dignity, if he can. And if not, then you've done all you can do."
"I guess...," I mumbled.
Marion patted me lightly on the back and walked away. I finished writing my progress notes and returned the chart to the shelf. No time to dwell on it. I had to move on to my next patient. Spinning slowly on my swivel stool I scanned the unit. Kathy was nowhere in sight. I walked briskly around the perimeter, checking each room as I passed by.
Have you seen Kathy Mummon?" I asked one of the medical students standing by the coffee pot.
"I think she went out on a pass with Barb," he said. He awkwardly ripped open a new bag of cups, spilling styrofoam cups all over the floor. "Damn it! Nothing is going right today."
"Welcome to the club," I answered. I helped him pick up, then went back to the nursing station to check the sign-in sheet. Kathy and Barb were due back any minute. As I walked towards the door I saw them coming down the hallway. I swung open the door so Barb could help Kathy steer in.
"Are we late?" Barb asked with surprise. "We tried to make it back in time for your appointment."
"No, you're right on time," I replied.
Kathy drove her motorized wheelchair through the doorway, running over my toes as she passed by. Her startled eyes darted up to look at me. "Oh! Was that your foot? I'm sorry Dr. Holden. Are you all right?"
"Fine," I replied as I grimaced. Motorized wheelchairs are heavier than you would imagine. "Just grazed me... So, how are you doing Kathy?"
"O.K., I guess."
"She's doing great," Barb added bubbly. "We went all the way around to the other side of the hospital and back. She's doing much better with her hand."
"Turning into a regular hot-rodder, huh?" I said. Kathy giggled.
"Would you mind if I joined you two today," Barb asked.
"No, not at all. Let's go to Kathy's room to talk." We followed behind the wheelchair as Kathy buzzed around the perimeter of the unit.
Kathy was a quadriplegic. After her high school prom she went for a ride on a motorcycle with one of the restaurant busboys. She was very emotional, uninhibited young woman - some would say carefree. We psychologists would call it "impulsive." Under the influence of alcohol - as on the night of the prom - her histrionics escalate to the point of melodrama. I'm sure she was the life of the party, more life than the party could handle. So she, in her chiffon dress, and Ronaldo, in his busboy whites, left to cruise around town for an hour or so, then parked at Lover Heights over the beach. Ronaldo didn't get very far that dark night, but Kathy fell from the cliffs. She would have drowned if he hadn't pulled her away from the incoming tide. Intensive therapy at a local hospital succeeded in helping her recover partial use of her right arm. Despite this modest physical progress, her psychological condition deteriorated rapidly. She became depressed and withdrawn. She feared the devil was plotting to kidnap her. At night she heard men's voices in her closet. The staff quickly decided to ambulance her over to us for psychiatric treatment.
Barb and I followed Kathy into her room and sat down on the edge of the bed. After a few bumps into the furniture, Kathy managed to maneuver the wheelchair around to face us. She seemed better, almost cheerful. Within two weeks after her admission the medications had succeeded in alleviating her depression. Her hallucinations and delusional thinking also lost much of their steam. Soon after her arrival Fred concluded that the psychotic symptoms were caused by the depression and that antidepressant medications, rather than major tranquilizers, were needed. It looked like he was right. Sometimes making a differential diagnosis between depression and psychosis is a chicken-or-egg dilemma: being severely depressed can culminate in hallucinations and delusions; being schizophrenic can make you depressed.
"So, Kathy, you seem to be making progress," I said.
"I feel better," she replied, "at least better than when I first got here."
"She's doing great," Barb interjected. "We were joking around and laughing before. And she's been talking to some of the patients, making friends. She and Rachel had a nice chat last night. And this afternoon we're going to do your hair. Right?"
Yeah," Kathy agreed. "And Barb said I might be able to go to the movies this week, with the other patients. I'd like that. I'm sick of being cooped up in this place."
"That's a possibility," I said, "although Barb and I will have talk to the team about that. A pass off the unit is a big step.... How did you sleep last night?"
"Fine."
"Didn't have a hard time falling asleep, or wake up during the night?"
"No."
"Didn't hear any voices?"
"No," she said cautiously as she glanced towards Barb. "I haven't heard those for a while.... I was under a lot of stress."
"That's right," Barb added. "She's been sleeping straight through the night without any problems. And she hasn't had any anxiety attacks since that one last week."
"Great," I said after hesitating. "I also wanted to ask you if you still have any thoughts about hurting yourself."
"Not really."
"Not really? I'm not sure what that means."
"It means ... not really. I mean, I guess the thought does cross my mind once in a while, but I don't take it seriously. I wouldn't actually do it, or anything like that. I mean, how could I even do it?... I hardly think about it at all."
She avoided making eye contact with me. Her fingers danced nervously on the control lever for the wheelchair. After a long sigh, she closed her eyes.
"You seem tired," Barb said. "That long walk ... I mean ride probably wore you out. It might be a good idea to take a nap sometime today."
"Yeah, a nap!" Kathy replied as she opened one eye. "That would be great."
"The reason why I asked about your hurting yourself," I interjected, "is that it's important to talk about. When you first came here you were troubled by suicidal thoughts. You were under a lot of stress. It would be perfectly understandable if you still felt a little depressed. What's important is that we talk about it if you start thinking about - "
The wheelchair suddenly lunged forward. Barb and I jumped. The wheels just barely missed her ankle, but my funny bone received a smart rap from the chair's armrest. It couldn't have been a more perfect shot to the nerve. A wave of tingling fire rippled through my arm. The pen dropped from my hand.
"Oh shit!" Kathy yelled. "I accidentally hit the lever. I can't believe I did that!"
"Are you O.K?" Barb asked.
"Yeah, I'm O.K.," I sputtered. "Nothing a few push-ups couldn't cure." The burning sensation turned to pins-and-needles. Slightly paralyzed, I had trouble picking up the pen.
"I'm really sorry, Dr. Holden," Kathy continued. "I'm such a jerk. I have to learn how to work this thing better."
"Practice will make perfect," I replied as I sat back down on the bed. My aching arm distracted me. "So... what were we talking about?"
"I don't remember," Kathy quickly answered, "but there is something I wanted to ask you."
"What's that?"
"When am I going to be discharged?" she asked politely, but very intent on my answer.
"Well, we have to talk about that some more. You haven't been here that long, and we want to make sure you're safe before we discharge you."
"Oh! I don't want to be discharged."
"You don't?" I echoed quizzically. "Just a minute ago you were saying that you're feeling good, and that you want to go on an outside pass. But you don't think you're ready to go home?"
"Oh, I'm ready to go home, it's just that I don't ... want to. You know ... I mean I sort of like it here sometimes. I like the people, I'll miss them when I leave. Everyone has been pretty good to me. It's nice here ... well, nicer than home."
"Nicer than home?"
"I think she means her family," Barb said with sympathy in her voice. "She and her mother have been having problems. Isn't that so?"
Kathy's face flushed. She began fidgeting with the control lever again. I folded my arms, cupping my hand to protect my elbow.
"Yeah ... my mother and I are always at it. She just won't leave me alone, always telling me what to do. I wish she would just get off my back. I'm 18 years old, not a baby anymore. Like yesterday, she was in here bothering me about being in the hospital. I don't know how long I'll be here. It's not my fault! She doesn't even really care about me coming home, so maybe I won't! When I get out of here I'll go somewhere else, I'll... I'll..."
She gasped for air, as if choking on her own thoughts. Her eyes shifted back and forth, searching frantically for an answer. But within seconds she jammed. Her eyes froze, then fluttered and rolled back into her head. Her arm dropped from the chair and hung limply at her side.
"I'm dizzy ... everything's sp - ... spinning ... I think I'm gonna be sick."
Barb sprang forward to put her arms around Kathy's shoulders. "Take it easy. Just relax and you'll be O.K. Breathe slowly and deeply ... in and out, slowly ... that's good." She looked up at me, "I think maybe we should stop now."
"I think you're right," I answered. I reached forward and placed my hand on Kathy's arm. "I know it's hard talking about these things. Your life is hard right now, and it's scary not knowing what's going to happen in the future. But we'll talk about this, we'll help you sort things out."
Kathy, with her eyes closed, remained withdrawn and silent. I wasn't sure if she was listening. After what seemed like a long pause, I decided to break the silence. "I'll stop in later to see how you're doing."
"I'll stay for a few minutes," Barb said as I stood up.
I nodded. "Let's talk later."
"Thank you, Dr. Holden," Kathy called out to me as I approached the door. I smiled back, and left.
I felt bad. Perhaps I shouldn't have pushed her on the issue about suicide. But I was worried about her. Despite the fact that she had improved, my guts told me that her high spirits were very brittle, that beneath the facade she was still very fragile and possibly even suicidal. Should I leave it alone, or explore it? That's an ongoing question in this inpatient work. During the short time that patients are here, our primary goal is to stabilize them with medications and supportive therapy so they can get out and back to their life. If you accomplish that much, the icing on the cake is to help them recognize their underlying psychological sore spots which are not treatable by medications. Some of those sore spots may have been developing over the course of many years. They've become deeply embedded in their psyche. The patient needs to confront these problems, but forcing them to do so now may just make them worse. Is it wise to open up a can a worms? It could take years of therapy to work out those problems. I was slowly coming to the conclusion that we treat some very serious problems with bandaids. We try to patch up the surface wounds and then send people along their way - but the hidden, deeper sickness often remains untouched, and will, inevitably, come back to haunt the person.
As I finished up my progress notes, I saw Barb cautiously walking towards me. She bit her lip, then smiled. I knew what was bothering her.
"Did I push her a little too hard?" I said.
"Well, I feel sorry for Kathy," she answered apologetically. "She's trying as hard as she can. Don't you think we need to encourage her more, let her know she's doing O.K.?"
"Yeah, you're right. For one thing, we need to encourage her to plan for the future. She feels very protected and supported here - which is both good and bad. The bad part is that she can't stay here forever. We have to help her learn how to fend for herself."
"She needs help dealing with her mother," Barb said. "I really doubt that she can face going home unless we do something to help them. I'm not exactly sure what's gone wrong in their relationship, but Kathy is very angry with her. She says she feels smothered."
"Smothered? I bet she feels smothered in a lot of ways. Just think of it. We have here a teenager, a girl who's used to impulsive acting out, being wild and unruly - and all of a sudden she's a quadriplegic - completely paralyzed! Her old style of dealing with her conflicts won't work any more. Literally, she can't run away from her feelings. She's forced to just sit here, stewing in them. It's no wonder she became psychotic and suicidal. She feels totally helpless."
Barb seemed to be thinking intently. "So what can we do to help her?" she asked. I sighed."Well, with a really good outpatient psychotherapist in addition to her physical therapy, who knows how far she could go. I've heard there's a really excellent psychologist at Hillside who specializes in working with patients with neurological problems. We should give him a call."
"So what's the intense discussion going on here?" a voice interjected from over my shoulder. Marion could smell problems at 50 paces, particularly when her teammates or patients were involved. She always intended to help, and usually did.
"I was telling Barb about Correll at Hillside Hospital," I said. "He'd be the perfect referral for Kathy when she's discharged, don't you think?"
"Yes, he'd be excellent. But you might as well forget him," Marion said matter-of-factly. "He's a first rate psychologist with first rate fees. Kathy could never afford it."
"She has insurance, doesn't she?" Barb asked.
"No. Last night I spoke to Mrs. Mummon. She was very embarrassed about the whole thing, but she finally told me about her financial situation. Neither she nor Kathy have any kind of insurance. I'm not even sure how Kathy's hospitalization here will be paid for. They're living in poverty. Their one room apartment has no heat, they sleep on an old mattress on the floor. About all they eat is pasta and corn flakes. A year ago Mr. Mummon disappeared. Mrs. Mummon took a job to try to support the family and pay off the loans he left behind. She quit a few months later, so she didn't qualify for unemployment. They have welfare, but that's about it."
"Why did she quit her job?" I asked.
"She's a high school dropout. The only job she could find was cleaning toilets at the bus station - the night shift - with addicts, muggers, and perverts to keep her company. She hated it."
I twirled the pen between my fingers, thinking about how impossible this situation was for Kathy. What, if anything, could psychology do for her? As I started to speak, the phone rang. Barb answered it, then handed it to me. "It's the police!" she whispered.
"The police?" Not knowing what to expect, I cautiously held the receiver to my ear. The sergeant's matter-of-fact voice on the other end was clear enough. Technically, the phone worked just fine. But the words rang hollow and unreal - as if their meaning had dropped out the bottom. I mumbled something in reply and hung up without saying good-bye. Marion and Barb were studying my face.
"What is it?" Marion said.
How can I say it? My face felt like rubber. My voice was flat. "Elizabeth was hit by a car this morning. She's dead. The police wondered if it was suicide."
"Oh my god!" Marion murmured. Barb's face sank, her eyes filled with tears. As Marion put an arm around her shoulder, I looked away. Their voices faded somewhere into the distance. Time and space flattened out. Across the room Phil still labored with the door.
"Are you O.K?" Barb asked after an indeterminate amount of time.
"Yes... I guess... I have to get back to work."
Marion touched me on the arm. "Stop by my office later," she said. "We should talk." As she walked away I reached for Elizabeth's chart on the "To Be Filed" shelf. Sitting in a hidden corner of the nurse's station, I wrote the addendum to her progress notes.
"Progress," I muttered to myself.
A distorted face stared back at me from the metallic coffee cup by my elbow. I tilted my head from left to right in a futile attempt to straighten out that head.