Because I Come from a Crazy Family

by Edward M. Hallowell

  I was doing my best imitation of a real psychiatrist, sitting next to a man who was, without doubt, real. Whoever he was, whatever his story, whatever was going through his mind as Professor Stein smoked his cigarettes and sat next to me, it was real.

  I began to feel annoyed with John Ratey for leaving us with such scant instruction. On the medical wards, they told us exactly how to insert an IV, how to do an EKG, how to perform a lumbar puncture, how to insert a catheter or an NG tube. And if ever we felt lost, they told us to always ask for help; seek counsel from a resident, a nurse, or an attending. Help was always nearby and we should never proceed without knowing what we were doing.

  Ha! Here I was with no idea what I was doing, other than my chief resident’s advice to “sit with the patient.” I’d been told to “figure it out.” There was no rulebook to follow, and as much as that’s what drew me into psychiatry, now I was feeling frustrated.

  I don’t know how much time elapsed before the professor broke the ice. It felt like an hour—but he’d had three cigarettes, so maybe it’d been twenty minutes—when Professor Stein finally asked, “Do you play bridge?”

  56.

  “Why is he called Professor?” I asked Linda, the head nurse. We were both sitting at the nurses’ station, one of the rare moments you could find Linda sitting down. She was drinking a coffee she’d just poured herself from the stale pot on the table next to the chart rack.

  “Because he was a professor, of physics, at MIT, supposedly one of the youngest to get tenure. But that was a long time ago. He had his first breakdown when he was in his twenties, I think. I should know ’cuz I’ve heard his case presented so many times. He’s had more residents take care of him than just about anyone here, maybe except Freddy. He’s been in and out for decades.”

  “Does he have any family?”

  “No one that he’s still in touch with, at least as far as I know. Way back, some MIT faculty would visit him, but they stopped coming a long time ago. In case you haven’t noticed, friends and families give up on these people. It’s sad, because the patients who do best are the ones friends and family stick with. If you want my advice, when possible, involve the family. It makes all the difference.”

  “He’s not my patient, I was just trying to get to know him.”

  “Oh. Well, good for you. Another piece of advice, if you want it: Spend more time with the patients than anything else. Lots of residents spend all their time hanging out here in the nurses’ station or in supervision or in seminars. That’s fine, but your real learning comes from spending time with these people.” Linda motioned to the patients in the day room, each sitting in their own particular world. “Lots of residents say they don’t have time to do that. My advice is to make time. They really are your best teachers.”

  Linda was a petite Italian beauty who understood patients better than just about anyone else at MMHC. I always wanted her advice. Everyone loved Linda. It would be so easy to fall in love with her.

  I got back down to business. “I have Kenny Luongo on my list of patients assigned to me. Has he been here a while?”

  “Not too long,” Linda said. “He was refusing meds when the old residents left, so you’ll be getting some pressure to get him on meds.”

  “Why won’t he take them?” I asked.

  “Well, handsome, for one reason, he’s crazy.” Linda gave me a little punch to my arm.

  “Can he talk about why he doesn’t want to take meds?”

  “Sure, but it won’t make sense. Give it a try, though.”

  This time I did look at the chart. Flying blind had a theoretical appeal but practical shortcomings. Kenny was twenty-four, admitted two weeks before I arrived at MMHC, and had been under the care of a resident I knew and respected. Kenny was refusing medication because he thought it was dangerous. The last progress note said Kenny was “incoherent and psychotic” and unable to have a meaningful discussion about his care. The advice was to appeal for a court order to medicate.

  I had to ask Greg, one of the attendants, to point out Kenny to me in the day room, as I’d never met him.

  “He’s over by the window,” Greg said. “He can stand and stare out that window for hours. Don’t come up from behind him. He’s like a horse. He scares real easy and doesn’t like it one bit.”

  I sat in a chair about six feet to Kenny’s left, well within his sightline, should he look my way, but to the side enough that he didn’t need to look at me if he didn’t want to. A basic lesson we were being taught about paranoid people was never to confront them. Leston Havens called this the counterprojective technique. Since projection is the chief defense mechanism in paranoia, you counter that process by siding with it, not getting in its way.

  The natural response to a paranoid statement is to argue with it. If a friend says, “My boss hates me,” you tend to say, “How do you know?” or even, “Are you sure you’re not being paranoid?” But if a truly paranoid person says that his boss hates him, it’s better to reply, “That must make working for him really tough,” or something empathic like that. The goal is to create an alliance, at least in the beginning, not to ascertain the truth.

  I sat a while to see if Kenny might look my way. After five minutes or so, he did. Then he looked back out the window. I waited longer, not looking at him but staying put. After another five minutes he pulled a cigarette out of his rolled-up sleeve, then bounded over. Standing above me, shifting from one foot to the other, he hurriedly asked, “Hey, man, you got a light?”

  Damn. I didn’t. I would learn to carry matches. “No, but I can get you one.”

  “Fuck off,” he said, and returned to his spot. I went and got a book of matches just the same. I went back to my chair, saying “I have matches if you still want them.”

  “Fuck you,” he said, holding the unlit cigarette. Then he walked back over, cigarette in his mouth, and leaned down for me to light it.

  I struck the match. Kenny accepted the light, and took a long drag. “Thanks, man.”

  “Kenny, I’m Dr. Hallowell. I’m your new doctor.”

  “That’s cool.”

  “Wanna sit down?”

  “No.” He stayed standing, smoking. I remained sitting.

  “Nice to meet you, then. Maybe we talk again another time?”

  “No chance,” Kenny said. Note to Ned: Paranoid people do not like closeness. This was a hard lesson for me to learn because my natural tendency was the opposite. Having grown up in my enmeshed family, I left doors unlocked, lent out everything I owned, didn’t balance my checkbook, and reflexively trusted everyone. I had to learn that many other people trusted no one.

  A few days later, I approached Kenny again. He was at his usual perch. This time I had a light to offer him, which he accepted. This time he sat down in a chair next to me in the day room.

  We sat side by side, looking out at the room and not speaking for a while. Then I asked if he was being taken good care of. He nodded. I asked if he was eating all right. He nodded. Since the nurses’ notes continued to report that he was psychotic, I felt the need to bring up the issue of medication, but I didn’t want him to freak out.

  “By the way, Kenny, there’s some medication that might be helpful to you. Could we talk about that?”

  “No.”

  “Well, of course you don’t have to talk about it if you don’t want to, but could you maybe tell me why you don’t want to?”

  No response. I began to think Kenny wasn’t going to reply at all when he blurted out, “It’s personal.” Then he waited several seconds before adding, “It’s so personal even I don’t know why.”

  Kenny may have been psychotic, but that was one of the most astute remarks I’d ever heard.

  At that time, the issue of forced medication was in flux. The era of doing psychotherapy with psychotic patients, championed at MMHC by elder wise men and women like Semrad, Max Day, and Doris Benaron, was slowly coming to an end. I loved talking with psychotic patients, but I also knew that
talk could not fix their psychosis nearly as well as medication could. Still, a human relationship would help them, no matter what.

  This was liberal Massachusetts, this was Harvard. This was the epicenter of patients’ rights, where patients were “allowed to rot with their rights on,” as Tom Gutheil put it. It was odd and, to my way of thinking, unfortunate that so many people championed the right of a patient to remain psychotic, as if that were a precious right to be preserved at any cost.

  Almost none of us—liberal, conservative, or disinterested—who were charged with taking care of these patients saw it that way. It had nothing to do with politics, it had only to do with what we believed was the best possible care we could provide. Letting a person stay in a psychotic state was, in our view, like allowing a patient to writhe in pain without intervention.

  Psychosis hurts. As one of my patients said to me, “I take such a shellacking from the voices.” Hearing voices inside your head—intrusive, unwanted voices called auditory hallucinations—is extremely upsetting. One of the many reasons that the auditory hallucination I had at age eleven was unique is that it didn’t upset me in the least. Hearing voices is torture for most people.

  And when the voices start telling you terrible things—like that you are being controlled by a machine at Logan Airport, or that the CIA is following your every move, or that your food is poisoned, or, worst of all, that you should kill a specific person or yourself—then you want to hold your head and scream, which many psychotic people do.

  Those last are called “command hallucinations,” voices that tell you to do certain things, the most awful being to kill other people or yourself. To make matters worse, for reasons I don’t understand, it is extremely difficult not to obey those voices. The person hearing the voices is not able to say what I was able to say the one time I heard a voice inside my head, “Gee, that’s interesting, let me give it some thought.”

  Instead, the person feels compelled to obey. They hate and fear the voices to the point that sometimes they commit suicide to escape the voices. So the development of medications that could take away the voices was a major step forward in treatment.

  But what was I to do with Kenny? He had his personal reasons—unknown even to him, as he so poignantly expressed—for refusing antipsychotic medication. I could try to use logic with him, or I could go before a judge and obtain an order to medicate Kenny against his will.

  Going before a judge wasn’t as cumbersome as it sounds, because judges came to the hospital on a regular basis to hear cases like Kenny’s. But after you obtained the order from the judge, what happened next wasn’t always pretty. If the patient wouldn’t agree to swallow the medicine, he’d have to be held down by attendants and have the medication injected. Even though it was legal and in the patient’s best interests, it felt like a violation, which is in part why the people who stood up for patients’ rights objected so vehemently.

  When it was an emergency, we didn’t have to go before a judge. But in Kenny’s case, a judge would have to hear the case. It was extremely rare—in fact, I can never recall its happening—that a judge did not go along with what we recommended.

  In the back of my mind, I never forgot my father telling me how much he feared and hated the insulin shock treatments he was subjected to. He said they were far worse than electric shock treatment.

  “I didn’t like the electric shock,” he said, “but the insulin shock, that was a bastard.” We were driving in a car when he told me this, I don’t remember when or where. It was one of the few times Dad ever talked about his treatments. “They’d tie me down, then inject me with insulin, and I’d spiral off. It was like I went straight to hell. I became incredibly strong, I fought like mad, I wanted to rip people’s heads off, it was pure torture. They don’t do it anymore, thank God. Whoever invented it was a mean sonofabitch, I can tell you that.”

  Often, when I saw a patient being held down and injected, I thought of Dad. Then I’d tell myself that this was totally different, this patient was out of control and needed help before he hurt himself or someone else.

  We did end up medicating Kenny against his wishes. Faced with the prospect of swallowing a pill or being held down and injected, he chose to swallow the pill, cursing us, especially me, all the while.

  But unlike my dad, I do not believe Kenny will ever regret the treatment he received. The medication cleared his psychosis in days, so that he became able to converse meaningfully with me, with the staff, with other patients, participate in groups, exercise, and make progress.

  By the time I finished my training I’d seen enough examples like Kenny to feel almost no compunction about seeking forced medication treatment. Indeed, I would have felt guilty if I hadn’t sought it. The potential benefits are huge, and if it is done properly, the risks are very low. The risks of not treating far, far exceed the risks of treating.

  57.

  “Division by zero,” Rodney said to me while straightening his vest. We were sitting in the day room in two chairs next to each other. It was the middle of the afternoon, and surprisingly quiet, with most of the patients in groups or out on walks. Rodney was not my patient, but I enjoyed chatting with him. “It makes no sense that they call it undefined,” he said. “If you can multiply by zero and if division is the inverse of multiplication, why in the world can’t you divide by zero?” Rodney always dressed in as dapper a fashion as he could, retrieving clothes from the hospital’s lost-and-found and collection of donated clothing. He described himself as “the best dressed lunatic in Boston.” He meant it affectionately, as he held lunacy in high regard. “Most geniuses are crazy, you know that don’t you?” he said to me once.

  “Rodney, have you sent off your paper?” I asked. We had an ongoing conversation about his paper. I wanted to encourage him, but at the same time help him be cautious.

  “Yes, of course. It will get rejected again, but I will keep trying until I prevail.”

  “Maybe try a less illustrious journal than Science? Is there some journal that likes offbeat articles?”

  “My good doctor, the point I am trying to prove is an illustrious point! It’s not offbeat. I want to give division by zero the place it deserves not only in mathematics but in the human experience.”

  “What do you mean, Rodney? I don’t think many people think about division by zero as they go about their daily lives. It’s not really a part of most people’s human experience.”

  “Of course they don’t. Any more than they think about splitting the atom, but that doesn’t mean it doesn’t have a profound impact on how they live.”

  “But Rodney, how does division by zero affect anyone’s life?”

  “Because it is undefined! What a ridiculous category for something as fundamental as that! Remember, there was a time when the smartest, wisest people in the world knew the world was flat! Where are they now? What do we ‘know’ now that is as fundamentally wrong as that? At least we call division by zero undefined, instead of calling it flat.”

  “Well, I just don’t want you to get your hopes up, then have them dashed.”

  “Oh, Dr. Hallowell, you are such a kind, young doctor. But you have much to learn about life. Life will teach you that it’s all about getting your hopes up, then having them dashed, then getting them up again.”

  I thought of Samuel Johnson’s line, “Life is a progress not from pleasure to pleasure but from hope to hope.”

  “I guess you are a wise man, Rodney,” I said.

  He straightened his vest again. “Why thank you, my good sir.”

  On any given day, there were about forty patients on Service One, each quite an individual. Diagnoses like schizophrenia and bipolar disorder were common, but they told you little about the actual person. One of the great advantages of training at MMHC at this time was that we were all encouraged to get to know each patient as a person, not a diagnosis. This came from Semrad, who used to say, “The patient is the textbook. Spend time sitting in the day room with patients
, instead of the library.”

  Eric Kandel, who trained at Mass Mental and went on to win a Nobel Prize in Physiology or Medicine, took strong issue with that statement, scorning it as anti-intellectual. But I think Kandel and Semrad represent opposite sides of the same coin: the coin being the road to truth, in this instance the truth of the patient. You might say Semrad took the Shakespearean road, Kandel the Newtonian. In any case, both were great teachers. (Kandel still is.)

  I never thought of Rodney as schizophrenic, which was his diagnosis, or as a lunatic, which was how he diagnosed himself. He was simply Rodney. To paraphrase a well-known line, there’s far more in human nature than was ever dreamt of in the diagnostic manual.

  We needed diagnoses to guide treatment, to do research, to communicate with each other and families and the world, of course, but I still always thought of Rodney as “the best dressed lunatic in Boston” rather than the schizophrenic in room 4.

  58.

  Sitting at a table in the day room, playing bridge with Professor Stein and two new patients, I felt the presence of someone behind me.

  “Melanie, are you peeking so you can give me some tips?” asked Professor Stein.