Because I Come from a Crazy Family

by Edward M. Hallowell

  I still have not officially terminated with Dr. Khantzian. One of us will die before that happens. A classical analyst might object to this, but if they knew the whole story, I don’t think they would.

  53.

  “It is love that brings them to us and love that sends them away,” said Elvin Semrad, who, soon after seeing a patient and then frying an egg in a skillet on the hot plate he kept next to his desk in his office, fell dead of a heart attack. Although that was a year before I got to MMHC, Semrad influenced me more than any figure in the field of psychiatry through the oral tradition he left behind.

  In its heyday MMHC, both a state hospital and a Harvard teaching hospital, stood as the premier training program in the country, and Semrad, by training so many psychiatrists who would go on to other parts of the country to lead countless other training programs, shaped the thinking and practice of thousands of psychiatrists.

  “A hayseed from Nebraska,” as he called himself, Semrad was a wildflower for sure in the fiercely intellectual, competitively cerebral Boston psychoanalytic community, which was deeply rooted in the Viennese tradition of Freud. He no more fit in with them than a square dancer in a ballet. But Semrad had an uncanny and undeniable genius for connecting with and understanding people, a talent that many tried to emulate but few could replicate. Even the brainiest analyst had to admit Semrad had a gift few, if any, of them could match. He influenced deeply a generation of psychiatrists, including, indirectly, others like me.

  Today, I still feel him with me, this teacher I never met, a guiding star in a field that always has been, and likely always will be, trying to find its bearings, until, as Freud himself envisioned, it deepens its roots sufficiently in basic science to get swallowed up as a subspecialty of medicine, neurology, and neurosurgery and disappears forever.

  Today we are closer to Freud’s dream than ever before, which is mostly to the good. We have brain scans of various types that have enhanced both our understanding of how the brain works and our ability to diagnose. We have an array of medications that can relieve suffering as never before, and we have standards of diagnosis that are becoming ever more precise. And we’ve added to our therapeutic arsenal many new interventions, like surgery for deep brain stimulation; vagal nerve stimulation or transcranial magnetic stimulation to alleviate intractable depression or obsessive compulsive disorder; old drugs with new applications, like ketamine for depression or 3,4-methylenedioxymethamphetamine (MDMA, called on the street Molly or Ecstasy) for post-traumatic stress disorder (PTSD); eye movement desensitization and reprocessing (EMDR) also for PTSD; and dialectical behavioral therapy (DBT) for a host of conditions, especially borderline personality disorder, which for decades was so intractable.

  When I started my residency in 1979, psychiatry, once the field of “talk therapy,” was focusing more and more on neuroscience. Coming of age in a field that was finally freeing itself from the rigid orthodoxies of traditional psychoanalysis and beginning to embrace the immense benefits of biological interventions, I was lucky enough to learn from both worlds, two groups of professors, one slowly fading but wise nonetheless, the other coming on strong, powerful tools in hand, and about to create a new orthodoxy. The brain was supplanting the mind before my very eyes.

  As always, the fanatics would do damage. We need an all-inclusive psychiatry, not a field divided by turf battles amongst egoists. Turf battles make me think of one of my favorite prayers: Lord, help me always to search for the truth, but spare me the company of those who have found it. At MMHC, we had teachers (called supervisors) who were analysts or had grown up in the analytic tradition, but the staff had no fanatic Freudians. Quite the opposite. There were people like Les Havens, Tom Gutheil, Irv Taube, and Doris Benaron who, while psychoanalysts by training, were humanists by disposition. They favored the way of Semrad: Go where the patient is. Follow the feelings. Use empathy to guide you.

  And the leaders of brain science at MMHC, the advocates of the biological interventions—Allan Hobson, Joe Schildkraut, Richard Shader, Carl Salzman—also insisted we learn and practice the skills of forming an alliance, understanding the patient’s life, and staying with feelings even as we were making a diagnosis and prescribing a medication or other biological intervention.

  For us residents, what could have been turf wars instead became the sharing of knowledge and ideas, each camp offering what it had and eager to learn from the other. That may sound too good to be true, but it’s what we, or at least I, experienced every day in my training. It couldn’t have been better.

  But for all the theories and ideologies, there was—and still is—only one group of patients. There were and always will be special cases whom we doctors came to know and love, in a manner unique in the varied world of loving relationships.

  These patients didn’t give a hoot whether psychoanalysis, biological psychiatry, interpersonal psychiatry, or colonic detox was the current craze. They simply presented themselves to us, in full puzzlement, on the off chance that we could somehow make a deal. They gave us their stories, their selves, and in so doing taught us in the best way possible. In return, we applied what knowledge and methods we had to try to improve their lives. For trainees, that was a great deal. For the patients, well, they drew the short straw, but they got the best we had to give.

  54.

  The morning we arrived at MMHC, all of us new first-year residents gathered in the modest hospital library, replete with oak tables, monogrammed Harvard chairs, thumbed-over classics, and obsolescent tomes. Greeting us were Dr. Miles Shore, Bullard Professor of Psychiatry at Harvard Medical School and superintendent of MMHC, along with our training director, Dr. Leon Shapiro, a tall, savvy psychoanalyst (actually, a training analyst, which is like a knight or a Jedi in that guild). Also present was Dr. Leston Havens, one of the most inspiring and learned mentors I would ever have.

  Havens, a man who did his best to empower residents not to feel intimidated by the brass, showed up seemingly fresh from a walk along the Charles River in Bermuda shorts and sandals, while Shapiro and Shore wore coats and ties, as did most of the other faculty there that day. They are a blur now, but then I looked at them as the guardians of the Holy Grail.

  Once each senior faculty expressed a few words of welcome that morning, it was announced that the first night on call would go to one Dr. Hallowell.

  Heading up to the fourth floor, I took the shaky, broken-down gray metal elevator. Lots of things at MMHC were gray metal, shaky, and broken-down, including desks, beds, chairs, and tables. I’d spend the next year in this ward—innocuously called Service One, one flight above Service Two—discovering that the cultures of these two services were as different as Dionysus and Apollo. Fittingly, I was on the Dionysian service.

  Instead of a stethoscope, I now carried a set of keys in my pocket. I would later write an essay “On the Transition from Stethoscope to Keys,” which Dr. Shapiro ridiculed as stupid and simple-minded, and he advised me not to enter it in the contest I had written it for.

  As his words took me back to sparring with Uncle Unger, of course I joined the joust. “Maybe I don’t want to write boring, psychoanalytic articles no one will ever read,” I replied.

  Shapiro smiled, as if he liked my spunk, rather than slapping down this rookie, first-year resident, for which I will always be grateful. But I did take his advice and did not enter the paper in the contest. However, a year later I submitted another paper in that contest, on the use of poetry in doing psychotherapy with a schizophrenic patient, and it won first prize, the Solomon Award, beating out the entry from Dr. Shore, who wrote on an innovative method of caring for the chronically mentally ill. That day I enjoyed what psychoanalysts—both Shore and Shapiro were psychoanalysts, because in their day becoming one was de rigueur—call an Oedipal victory. I had slain the father. This is often followed by anxiety and guilt, or by confidence and swagger. I felt all four.

  Now, instead of scrubs and a white jacket, I wore what most of us wore, casual stre
et clothes. We didn’t look like doctors. A few of us wore jacket and tie, which Dr. Shore applauded, but most took advantage of the freedom to dress down, which seemed more in keeping with the physical condition of this state hospital. It was a dump, but a dump patients loved and I came to love as well. It was a glorious dump, if you ask me. A true rag-and-bone shop of the heart.

  Upon arriving on the ward, the five of us new residents and the one psychology intern made our way to our offices, which John Ratey, our chief resident, had randomly assigned. The patients were milling around with obvious curiosity, like fish circling, checking us out, as were the nurses and attendants on duty. They’d awaited our coming, not knowing what kind of crop they’d get. The day before, they’d bidden farewell to the previous year’s residents, and now they were eager to see this new troupe of doctors in training. It made sense that they were eager, since in 1979 more than a few patients stayed at the facility for over a year. Some patients would be with us for a long time.

  However, when proceeding to my new office, I didn’t notice the patients right then. I had in mind another purpose altogether. I’d brought with me a poem I’d typed and framed. Dating back to college, I’d planned to hang this poem on the wall of my first psychiatry office, if I ever got one. Now that I was here, standing at the door of that office, I felt I should invoke some blessing. I paused and waited two beats. It’s the easiest way to make any moment special. Just wait two beats. Stop time.

  When I opened the door, it was love at first sight. No matter that the chairs were naugahyde, some with rips and tears, the desk was dented gray metal (of course), the windowpanes were filthy, there was a hole the size of a grapefruit in one wall with hairs of plaster hanging out of it, and another hole, this one the size of a bullet, in one of the windowpanes. I was just grateful there were windows, and four of them to boot, each with eight rows of four windowpanes. I was home at last.

  My view looked out onto Fenwood Road. Up the hill I could see the Peter Bent Brigham Hospital where the men and women who had been my fellow interns were at that same moment showing up for their first day of medical residency. I looked out my office window and gave them all a wave. What different lives we would now embark upon.

  Turning away from the window, I looked for a place to hang my poem. I’d brought a small hammer and hook with me, so all I needed to do now was to pick the spot.

  I chose the wall directly opposite the door, so I would see the poem every time I walked in. It would mean nothing to anyone else, except possibly those few who might get close enough to read it, but for me it set the stage for the coming year and for my entire career. It was W. H. Auden’s poem “Musée des Beaux Arts,” in which Auden uses Breughel’s painting of Icarus falling into the sea as a model for human suffering. In the poem he notes “how everything turns away quite leisurely from the disaster.” Even though the sailors on the ship had seen “something amazing, a boy falling out of the sky,” they took no notice as they sailed calmly along to wherever they were headed, the disaster, if even noticed, quite forgotten.

  I pounced on that poem in college and turned it into an emblem for my future work. Not only did it speak to the lives of the people I would treat, it spoke directly to me, to the loneliness and sadness I felt growing up, which the world couldn’t notice because it had somewhere to get to. Of course, my suffering was puny compared to that of the tens of millions of children who really had it bad, some of whom I would meet in the coming years, but my suffering was, in its own unimportant way, what I had to deal with.

  The patients at MMHC had it much worse than I could have imagined. I had no idea how tough the lives of the patients I would meet over the coming years really were. These patients were poor and crazy. There is no group more overlooked, if not outright despised, than the indigent mentally ill. It’s bad enough to have no money, but to be out of your mind as well? As far as the general public is concerned, you occupy the place lepers used to take.

  MMHC served as its own kind of leper colony. Politicians wanted no part of it, cutting its budget whenever they could. The hospital’s neighbors wished it weren’t there, and even the Harvard medical students who rotated through usually held their nose until their rotation blessedly came to an end. Most preferred to do their psychiatry rotation at McLean, the posh hospital where the well-heeled and oftentimes famous went for treatment.

  I chose the dump. As I put my feet up on my dented desk and tilted back (yes, I even had a chair that tilted), I felt I’d found my own special paradise.

  Perhaps because I’d always felt like an outsider, I felt instantly at home at this stopping place for those who did not belong anywhere: the marginalized, the misfits, the estranged. Misfits, take heart. We have a home. Welcome, O life! I go to encounter for the millionth time the reality of experience and to forge in the smithy of my soul …

  As all my compatriots left Service One to enjoy their day off that Sunday, I entwined my fingers behind my head, leaned back, stared out the 128 windows and through the one bullet hole, and thanked my lucky stars for landing me at MMHC.

  In years to come, I would have thanked God, but back then I was on leave from God. I thought about God, as I had done ever since my days in Charleston, but I didn’t pray regularly anymore or ever go to church, not since required church at Exeter and the sermons of Fred Buechner. Unless you couldn’t shake your Catholic upbringing or you were an Orthodox something—Jew, Muslim, Greek, Buddhist—medical training typically instilled extreme doubt, if not a sturdy atheism supported by science and logic.

  We saw too much senseless suffering to get past the obvious question everyone asks when they first learn how to question: How can there be a God if all this horror happens every day? Or, as my best friend in medical school, Steve Bishop, told me Martin Buber wrote, “If God is good, He is not God; and if God is God, He is not good.”

  I had no idea what my years at MMHC would lead me through, any more than my recent friends up the street at the Brigham knew what their years in medicine would lead them through, what changes, what joy, or, sometimes, what hardening of the heart.

  I thought of them, and imagined what they would think if they saw me now at MMHC. “What are you doing here in this dump?” Mark would ask in disbelief. “What a waste of talent. It’s not too late! Come join us!”

  I was committing to a stranger road, a road not widely respected by doctors or the general public, a road with few clear road signs or dependable destinations.

  In coming to MMHC I was joining my people, the wildflowers of this world, the people I grew up with, the people I understood in ways that most people can’t, people with whom I found it fun to hang out, as I did for hours on end in the day room, people most of the world fears and dislikes, but people whom I liked. I knew I could connect with them. I hoped I could even help.

  55.

  My second day of residency, I sat beside Professor Paul Stein in the day room. He was a tall, gaunt man with a tobacco-stained four-inch beard. Head nurse Linda had told me his name but that was all I knew about him. He was a patient at MMHC but not my patient. He was just a person I wanted to get to know. I was out in the fields again, with the people this world didn’t cultivate or care for.

  Standard practice is to read a patient’s chart before meeting them, to get background and context so as not to unknowingly stumble into sensitive areas. I didn’t want to do it that way. I preferred meeting a person without preconceptions. Why shouldn’t I meet him on the same terms he was to meet me? As in this case, many of my instincts went against regular procedures. The beauty of training at MMHC is that the powers that be encouraged innovation rather than always operating by the book, as long as what you did was safe and legal.

  So I met Professor Stein much as he met me, with no prior knowledge. Because my father had been saved by a young doctor’s taking a fresh look at my dad and radically changing his diagnosis and treatment, I knew on a personal level how wrong psychiatric diagnosis can be, how rigid treatment plans can bec
ome, and how valuable not knowing what’s been concluded by others can prove to be. Meeting Professor Stein cold provided me my one chance to see him through my eyes only.

  “Sit with the patient” had been Semrad’s command, and John Ratey, my chief resident, had also advised us to at first just sit with the patient. So there we sat: Professor Stein and me, him staring straight ahead, both hands on the arms of his high-backed chair, and me, in a folding chair next to him, turned forty-five degrees toward him so I could either look at him or join him in staring straight ahead. I was biting my tongue, holding back my desire to pepper him with questions.

  We sat in silence. He took out a cigarette and lit it. More silence …

  I was trying to get used to sitting next to someone and remaining quiet. People don’t generally do this in polite society. But this was not polite society. Here I was, freed of all the tests, technologies, and busyness of regular medicine, charged only with the task of connecting with another person. And so we sat.

  Finally, as if I’d held my breath as long as I could, I had to break the silence. “You’ve been here a while,” I said. Professor Stein just kept staring straight ahead.

  I began to wish I’d read the chart. Could he speak? Was he mute? What meds was he on? What diagnosis did he carry? Did he have family? Was he actually a professor, or was that a nickname?

  On and on we sat. He leaned forward and tipped his ash into the red plastic ashtray on the “coffee table” in front of us. I put it in quotes because so much at MMHC was ersatz. The patient “library” was a sitting room with shelves upon which happened to be a random assortment of tattered paperbacks and a few broken hardbacks. The “solarium” was a room that once had a skylight but now was sealed over. The “phlebotomists” were a couple of guys who wore T-shirts and carried toolboxes full of the equipment needed to draw blood. The “TV room” was a smallish room that had a semifunctional tabletop TV with rabbit ears. The “linen closet” was a closet stuffed with towels that looked to be older than I was. “Housekeeping” was a group of state employees who were spooked by the patients and spent as little time on the ward as they could. And the largest room, the “day room,” sported a motley assortment of “easy chairs” with steel frames and naugahyde cushions, rickety folding chairs, one “sofa” that had its stuffing popping out all over, and at one end of the room a “fireplace,” which, of course, was bricked over. Sometimes even I felt ersatz, having just days before been practicing real medicine as a real doctor in a real hospital, only now to find myself entering a field that the rest of the world joked about.