Gracefully Insane

by Alex Beam

  11

  Physician, Heal Thyself

  “Did you hear about Dr. Shein?” they asked.

  In 1967, Walter Jackson Freeman, the father of the ice-pick lobotomy, published a book called Psychiatrist: Personalities and Patterns. It is a generally undistinguished overview of the profession, for the most part a collection of poorly written profiles of Freeman’s heroes, the biologically oriented therapists like Manfred Sakel, the inventor of the insulin shock treatment, and António Egasmoniz, the Nobel Prize-winning lobotomy pioneer. Freeman, the archetypal hands-on kind of guy, lumped Sigmund Freud, Otto Rank, and Harry Stack Sullivan into one brief chapter called “The Great Theorists.” And yet, in a ghoulish final chapter entitled “Mortido: The Death Instinct,” Freeman hit on something. Eight of Freud’s closest disciples had killed themselves; why? He went on to suggest that “suicide might be called a vocational hazard for the psychiatrist.”

  Freeman was a crackpot enthusiast; maybe he was even a little mad.23 But the mad often have special insights, and Freeman pursued this one as far as it would go. There was no literature on psychiatric suicide, so Freeman did his own research. He combed the obituary notices of the Journal of the American Medical Association (JAMA) to prove his point. When a reported cause of death seemed suspicious, he addressed the relevant state Bureau of Vital Statistics, with mixed results. Although his findings were far from scientific, they were provocative. He reported that 203 American psychiatrists had committed suicide in the seventy years from 1895 to 1965. He deduced, convincingly, that suicides were underreported by the medical profession and also that this seemed like a high number. As with his hurry-up-time’s-a-wasting lobotomies in his medical office, his methodology was suspect. But yet again, his work commanded attention.

  Perhaps understandably, there is very little literature on the subject of psychiatric suicide. In 1980, two California psychiatrists revisited Freeman’s thesis, and—unlike most of his theories—it held up perfectly. Writing in the Journal of Clinical Psychiatry, Charles Rich and Ferris Pitts reported that “psychiatrists suicide regularly, year-by-year, at rates about twice those expected.” They used American Medical Association records instead of the JAMA obituaries that Freeman combed through; the JAMA understated suicide rates by about 20 percent, according to Rich and Pitts. But even this report was misleading, because they were comparing psychiatrists’ suicide rates to doctors’ suicide rates, which are considerably higher than those for the general population. The two authors even allowed themselves a moment of what must have been unintentional levity: “The occurrence of suicides by psychiatrists is quite constant year-to-year, indicating a relatively stable over-supply of depressed psychiatrists from which the suicides are produced.”

  Why do psychiatrists kill themselves? Many admit that they entered the profession to wrestle with their own demons—“to find out what was wrong with me,” is the phrase I heard over and over again. Rich and Pitts confirmed this. Massaging their data, they hypothesized that one in every three psychiatrists suffered from a mood disorder like mania or depression. This, they wrote, is three times the incidence in the general population: “This would logically imply that psychiatry is depressing to the practitioner and/or physicians with affective disorder tend to select psychiatry as a specialty. For a variety of reasons, we believe the latter to be the case.”

  Mental illness can be infectious. Nurses, psychiatric aides, and therapists are hardly indifferent to their surroundings in the mental hospital, and many of them break down themselves. As the doctors are fond of saying: No one is immune.

  It is not uncommon for psychiatrists to check themselves into a sanitarium or hospital, although they usually seek shelter outside their practice area to avoid the possible embarrassment of meeting patients or students inside the hospital. Boston doctors might travel to the Yale-New Haven Hospital or to the bucolic surroundings of Austen Riggs in Stockbridge, in the heart of the Berkshire mountains.

  But some ended up at McLean. One well-known patient was Dr. Doris Menzer-Benaron, a prominent member of the Boston Psychoanalytic Institute, who spent a good deal of time with the “crazy ladies” of Codman Hall. Benaron was married to a prominent local psychiatrist, and she had trained some of the doctors at McLean. For understandable reasons, she was regarded with great empathy by doctors and patients alike.

  Another sad case was that of Julia Altschule, who was married to Dr. Mark Altschule, a cardiologist who also functioned as McLean’s one-man research laboratory from 1947 through the early 1960s. Julia had been a ballerina and assumed a curious Asian affect as she grew old at McLean, diagnosed as a chronic schizophrenic. She often wreathed herself in a black shawl, and wandered the grounds along “Julia’s path,” which took her from Codman Hall, behind Eliot Chapel, down over the Bowl, down to the Pleasant Street Lodge and back again. Julia would occasionally stop and talk with small children, as she did with Harold Williams’s two-year-old son. What did they talk about? “God only knows,” Williams now says. “I never heard a sane word come out of her.”

  Nurse Maria Pugatch remembers seeing Julia at the head of the grand staircase in Upham Hall, where she lived for a time: “Imagine how spooky it was to come into this building, and there at the top of the stairs is this short little woman dressed entirely in black, speaking in a kind of a tongue. Sometimes when you drove into the hospital, she would be standing on the top of a hill, casting spells on you. Everyone said she was a witch.”

  Huddled in a tiny, one-room lab in a tunnel just beneath the main administration building, her husband devoted much of his life to discovering a cure for his wife’s illness. Working with pots and pans instead of test tubes and petri dishes, Altschule kept searching for the biological roots of his wife’s illness. He experimented with different megavitamin recipes, occasionally tube-feeding them to catatonic schizophrenics in the hopes of mobilizing them. He also tried to isolate an extract of the pineal gland, which he injected into schizophrenics, hoping for a cure. “Like all therapy in schizophrenia, it worked in the beginning, or seemed to, and didn’t lead anywhere,” remembers Dr. Alfred Pope, a friend and colleague of Altschule’s. “The pineal had been considered a vestigial organ that did nothing,” Pope adds, “and Mark deserved credit for putting it on the map. It turned out to be a minute but important organ, especially in relation to sleep mechanisms.” But it does not play a role in the neurobiology of schizophrenia.24

  Worse tragedies than a doctor’s wife’s madness were to befall the hospital. On Father’s Day, 1962, Williams, the hospital’s doctor on call, decided to look in on a young resident named Wellington Cu, whom Williams himself had urged to transfer to McLean from a post in New York City. Cu had been depressed and acting strangely. He had broken up with his girlfriend and was also having problems with the immigration authorities, who had threatened to deport him back to the Philippines. Cu, an ethnic Chinese, had been raised by his grandmother in Shanghai and did not speak Tagalog. As it happened, McLean’s suicide epidemic was in full swing. Cu’s friend and fellow resident Dr. John Ellenberg thinks as many as eight patients had killed themselves during the previous year. “There was this business of suicides going around,” he says, “and we were trying to figure out among ourselves why this was happening.” Dr. Captane Thomson encouraged Cu to emigrate to Canada, and the two men even bought a footlocker together. “‘That will be my casket,’ is what he said,” Thomson remembers. “He was dropping broad hints. We said, ‘Come on Wellington, don’t be so discouraged. We know you can get through this.’ You know how you try to jolly people along and help them out. None of us thought he would take his own life.”

  Mounting the stairs of Waverley House, the white clapboard three-story colonial home where the cheery young assistant Earl Bond had lived in 1909, Williams had a premonition of fear. “I had the feeling that someone was dead there,” says Williams, “and there he was lying on the bed.” On Father’s Day, Cu had taken his own life with an overdose of barbiturates—intended to be pa
ssed on to Cu’s sister—that his father had mailed to him from the Philippines. In a suicide note, Cu thanked all of his friends and wrote that if it hadn’t been for them he would have killed himself sooner. Then he explained that he had ingested twenty-six Seconal tablets, “one for every miserable year of my life.” Ellenberg remembers that the note carefully did not blame “this person or that person, so it was a list of everybody who could have possibly intervened. He accused everybody he could by saying he didn’t blame them.”

  In the presence of the dead body, Williams recalls, the two doctors had no idea what to do. “Luckily, Ellenberg had some religious training, and he had that to fall back on. We went back downstairs, he put on his hat and said, ‘Let’s have something to eat and say a prayer.’” In a neighboring bedroom, Ellenberg sang kaddish for the deceased Chinese-Filipino resident. “Then,” says Williams, “we wondered whom we should call first. We decided to call Stanton and ruin his entire month.” Once at the scene, even Stanton was not quite clear about the proper procedure for disposing of a corpse. Eventually they located an Episcopal priest who knew how to handle these things.

  “Wellington once said to me that the worst thing you can do to someone is to kill yourself on his doorstep,” Williams recalls. “Well, that’s exactly what he did to McLean.” More than a decade later, another doctor took aim at the hospital and hit squarely on the mark.

  During the years that I interviewed people for this book, I joked that I was actually building an impressive archive of tape-recorded restaurant and coffee shop sounds, what radio reporters call actuality. And indeed, I have put together a sort of audio field guide to clattering spoons, crashing crockery, and the repeat visits from solicitous serving people, asking me and my interviewee if everything was all right. My interview with Dr. Stephen Bergman falls into this category, a “sounds of Starbucks” classic. We met in a mini-mall near our homes in Newton, Massachusetts, a city that boasts the largest per capita infestation of psychiatrists and psychologists in America. Newton, inevitably dubbed a “leafy suburb” when sports announcers come by to cover a Boston College football game, is quite precious. Indeed, there was a protest of sorts when Starbucks opened the location where Bergman and I decided to meet, as the Seattle-based giant was invading the territory of a popular, previously existing coffee bar around the corner.

  Bergman, a tall, imposing, bald eagle of a man, is in his mid-fifties and has written three novels under the pen name Samuel Shem. He is well known in the Boston medical establishment, if not well liked. His first novel, House of God, was a bawdy, artfully written roman à clef about his year spent training in the emergency room of Boston’s Beth Israel Hospital. Relentlessly realistic (and thus unflattering) in its portrayal of the medical establishment, it alienated virtually every important doctor in the city, sold well, and has since become a classic among medical students. Bergman’s third novel was Mount Misery, a similarly disguised account of his psychiatric residency at McLean, where he developed an instant attachment to an intense, cigar-smoking young administrator named Harvey Shein.

  Bergman picks up his story after his stint at Beth Israel:I was all set to go Mass Mental [Massachusetts Mental Health Center] for my psychiatric training. But I thought okay, I’ll take a look at McLean. Back in the early ’70s, McLean had a reputation of not being a place where smart Harvard Medical School students wanted to go for their psychiatric training. It was a second-rate place in terms of who was out there. The first-rate place was Mass Mental. McLean was kind of this aristocratic backwater where rich patients went. They got the second tier of the medical school people who either weren’t very smart or weren’t very broad. So I wasn’t too interested in going there.

  But I decided to interview, so I went out there, and Harvey was one of the two people who interviewed me. The other one was some aristocratic guy who saw on my resume that I had been a Rhodes scholar and started talking about Oxford. Harvey was this short, dark-haired, intense guy who sat behind a pile of books smoking a cigar. He did something no one else had done, he looked at my resume, closed the thing said, “Okay, we’ll take you. What can I do to convince you to come here?”

  Then we had a really wonderful conversation. I respected him because he was both an analyst and he was interested in the neurochemistry of psychiatric illness, which also interested me. He had a very kind, down to earth, modest, humble manner and it was on the basis of that, and seeing the beautiful grounds and tennis courts—I had been up to my elbows in the blood and gore of the inner city at the Beth Israel emergency room—that I said, “Hey, I’m coming.”

  That was in 1974, really the first year that some of the top guys at the medical school decided to come to McLean. A big reason for that was the new director, Shervert Frazier. He was a real hotshot. He had been president of the American Psychiatric Association, he was an eclectic psychiatrist, and he was hell-bent on making McLean into a good place. He was from Texas, and he spoke in this deep drawl, and would say things like, “Y’know, I’m going to get the best people here.”

  One of the best people in Frazier’s stable was the forty-one-year-old Shein. The track is very fast at the Harvard Medical School, and Shein seemed to have covered more distance than any doctor of his generation. Shein hailed from a middle-class, not particularly religious family of reformed Jews living on the east side of Providence, Rhode Island, not far from Brown University. He attended Classical High School, the Providence equivalent of Boston’s competitive Latin schools, and then went on to Cornell to study philosophy. His childhood friend John Livingstone, who later joined Harvey at Harvard Medical School and McLean, describes Shein as an intellectual plunger who would dive into huge bodies of art or knowledge—the works of Stravinsky or Wittgenstein—and emerge renewed and ready for cerebral combat. “He was an incredible thinker and conceptualist,” says Livingstone. “He had an awesome, steel-trap mind. He was really argumentative, too. He’d argue with his parents, he would argue with me, he’d argue with anyone.”

  At Harvard, Shein landed a job in the virology lab of Dr. John Enders, a legendary figure in medical research who shared a 1954 Nobel Prize for his work on polio viruses. Later, he collaborated with Julius Axelrod, a biochemist who won the Nobel in 1970. One of Shein’s analysts, Helen Tartakoff, wrote a famous paper about the “Nobel Prize complex” that affected extraordinarily precocious young men, and she noted that their addiction to evergreater achievement and laurels could never be satisfied. Shein boasted to colleagues that he was the model for Tartakoff’s maternally indulged, perennially disappointed superachiever.

  In his mid-thirties, he reoriented his career to psychiatry and quickly made his mark at McLean. Before he turned forty, he was made director of residency training, the number-three clinical job at the hospital, and Frazier seemed to be grooming him for even more responsibility. In 1973, he appointed Shein psychiatrist-in-chief of Upham Hall, Louis Agassiz Shaw’s old haunt, to add administrative experience to Shein’s already impressive portfolio.

  Starting in 1968, Shein had begun to publish research papers on suicide. Writing with his colleague Alan Stone, Shein asserted that psychiatrists and mental hospitals had to change the way they treated suicidal patients. Shein and Stone argued that most patients talk openly about their suicidal intentions and would be willing to discuss them with their therapists. But doctors too often were reluctant to place suicide front and center in the “therapeutic alliance,” either because they feared upsetting an apparently stable patient or because they mistrusted their own motives. An overconcerned therapist might become enmeshed in a “rescue counter-transference,” meaning that the therapist might fall victim to a fantasy that he or she could save the patient’s life. The authors argued that suicide talk had to be brought into the open, not just in the doctor-patient relationship but throughout the hospital, to include nurses and ward aides in the course of treatment: “Suicidal intent must not be part of therapeutic confidentiality in a hospital setting.”

  Shein acknowl
edged that there are other possible avenues for treating suicide, for instance, electric shock. But if the therapist opts for the kind of open intervention that he and Stone espoused, one element is key:It is, of course, essential that the therapist take pains to make clear to the patient that he (the therapist) considers suicide to be a maladaptive action, irreversibly counter to the patient’s sane interests and goals.... It is equally essential that the therapist believe this; if not, he should not be treating the patient within the delicate human framework of psychotherapy. [Emphasis added]

  How odd. Why would Shein raise the possibility that a suicide counselor himself might not believe that life is worth living?

  The grim answer came in the summer of 1974. On the surface, Shein’s life continued its upward trend. With his impressive achievements in neurovirology and in psychiatric research, he seemed to have a lock on tenure at Harvard. His last published paper was “Loneliness and Interpersonal Isolation: Focus for Therapy with Schizophrenic Patients.” Shein no longer ran Upham, but he continued to oversee the residents and was handed some of the responsibilities of the clinical director, the hospital’s second-in-command and chief flak-catcher. “He was being pushed to get more clinical experience so he could be clinical director,” Irene Stiver said. “He was a brilliant researcher, but he was very young. I think he was overwhelmed.” Shein was overloaded as usual, but he had been allowed to cut back on his psychiatric load to compensate. One of his few patients was Livingston Taylor, who had already launched a successful singing and songwriting career and who memorialized his therapist in his best-known song, “Carolina Day.”

  There were smoke, then booze, then tokes

  then Herc

  And my head were dead and gone