Sometimes a person wants to die. Not just for a day, but week after week and month after month and year after year. One way or another, they are determined to make it happen. There’s only so much we can do, or should do, to prevent it. The dicey question is how much is too much?
I knew Hannah for only six months or so, but I always found a heroic quality about her. She struggled with a terrible condition for many years, doing her best to quell the most painful and destructive feelings a person can have. She fought to live, and in the end insisted on living life on her terms, with dignity and freedom, or not at all.
It was in knowing Hannah, and others like her, people whose courage and will to live burned fiercely even in the face of massive shame and self-hatred, of abuse and deprivation the likes of which I couldn’t imagine, that I started to believe again in what I’d been taught in St. Michael’s Church, and taught by Fred Buechner at Exeter and in Bill Alfred’s study at Harvard: We do not die, we live forever, there is life in the world to come.
I just could not imagine that the fervor with which Hannah lived, the courage, pride, and love that surged through her and kept her alive, no matter how challenged, humiliated, and defeated she felt, no matter how much the world ignored or despised her, no matter how much she despised herself, I couldn’t imagine that the part of her that could hope and feel love, the part of her that could sit in my office and say I want to give life a try could ever die. It simply felt impossible, like a violation of a basic rule of physics.
72.
Like many of the decisions in my life, deciding to go into child psychiatry was not planned or well thought out. I had no idea I’d do it until the very last minute, when I had to decide on a plan for my third year of residency. The decision I did make would change my life dramatically. If I hadn’t done it, I would never have learned about the condition that ended up becoming the center of my professional life: ADD.
After two years of residency in psychiatry at MMHC, we had to decide what to do for the third year. Various options were open to us. We could be a chief resident, what John Ratey had been for me when I was a first-year resident. We could do a year of psychopharmacology; a year of forensic psychiatry; a year of administrative and social psychiatry; a year of research; or a fellowship in child psychiatry, which, unlike the other options, required a two-year commitment.
None jumped out at me. But you couldn’t graduate and take the exam that makes you a board-certified psychiatrist unless, after medical school, you did an internship followed by three years of residency.
Child psychiatry seemed the most interesting option, but that extra year was a turn-off, especially since I’d already been in training for seven years after college. Still, the idea of playing with children and learning about child development seemed worth an extra year. Plus child training would give me an additional calling card, an additional area of expertise, making me more employable.
Truth be told, maybe the reason for my decision was so personal even I didn’t know why, as my patient Kenny Luongo so memorably taught me.
Whatever the case, that decision was to shape my career more than any other. I never could have anticipated or planned what was to happen in my child fellowship, no matter how long I thought it through or how many times I looked both ways.
73.
I didn’t know what to expect when I started my training in child psychiatry. I’d had a couple of adolescents in the adult inpatient unit in my first year of residency, patients who should not have been admitted to the adult unit but had to be because there were no open child beds in the state system.
One of those kids was particularly memorable. He said to me, “People are made of three things: vision, imagination, and the lack of the first two. Most people are ninety percent lacking of the first two, which is why I don’t like people.”
I’d also had an interesting moment in my second year when one of my outpatients brought her ten-year-old son, Tim, with her to her appointment. Tim asked me if I could help him stop wetting his bed.
The mom had explained to Tim that I was not a pediatrician or a child psychiatrist, but he wanted to ask me anyway, since none of the doctors he’d seen had been able to cure him. He’d taken the standard medications for bedwetting and followed the various behavioral regimens, but nothing worked.
In a moment of desperation, on an impulse, I made the following suggestion. “Tim, do you know that salt holds on to water? Well, it does. What I want you to do is before you go to bed, open a bag of potato chips and eat exactly three of them. Then seal the bag and go to sleep. The salt on the potato chips should hold on to the water so you won’t wet the bed.” Tim nodded as I told him this, and took it in as if I were handing him the ultimate solution.
The next time I saw the mom she gave me a hug and told me Tim’s bedwetting problem had been cured. The potato chips worked. Tim totally believed that the salt was holding on to the water.
It was one of my first lessons in the power of suggestion and placebo.
Beyond those two cases, I had no experience with children in psychiatry until I started my child training in 1981.
The first inpatient I was assigned in my child fellowship, which I also did at MMHC, was admitted on an emergency basis. I was paged to the unit, where I read the following brief admit note:
Mother accompanied son who was brought in by ambulance. History given by mother. 8 y.o. African American boy admitted after attempting to murder his sister by pouring lye down her throat and murder his mother by setting her mattress on fire. He himself had witnessed a murder the day before. No father present in his life. No prior admissions. No current medications or medical problems. Was medically cleared in Brigham E.R. before being sent to MMHC. Toxicology clean. Mental status delusional. Pt. is dressed appropriately but unable and unwilling to cooperate with interview. Appears to be responding to internal stimuli. Combative. Bit attendant so was put in seclusion room.
When I went to meet Tony, he looked up from the mattress on the floor where he lay, sat up, reached back, and threw a handful of feces at me. I ducked. The feces missed. I said, “Tony, I am Dr. Hallowell.”
In response, the boy growled.
I said, “I’ll come back to see you tomorrow,” closed the door, and left.
The next day I went to the same room, knocked, and entered. Tony was sitting on the mattress this time.
“Hi,” I said. “We met briefly yesterday. I’m your doctor, Dr. Hallowell.”
“I know,” Tony said, a big smile on his face. “I spent the night in your brain and crawled out your nose this morning.”
Tony was a strikingly handsome boy, almost like a young Denzel Washington. To see him in such a disturbed state was unnerving. When kids have problems, the same problems that adults have, they’re much more upsetting to everyone, caregivers included.
The Children’s Unit took up two floors: the ground floor for outpatient work and the second floor for inpatients. Like the adult units, it was physically a dump. But also, like the adult units, it attracted a hugely dedicated and idealistic staff. This was always what I loved about MMHC: All of us shared a belief in an impossible, romantic cause.
Take Tony. On the face of it, he was a hopeless case, even at age eight.
Actually, Tony made the diagnostic manual—at that time, the DSM-III—look ridiculous. He qualified for so many diagnoses it made your head spin, not to mention the problems that weren’t diagnoses per se but nonetheless posed huge problems: poverty, no father, hostile and dangerous neighborhood, overcrowded school, poor nutrition, minimal access to medical care, maximal access to guns and gangs.
All I could do was go where all ladders start, or in this case, where all treatment starts: the foul rag and bone shop of the heart. I had to get to know Tony.
A few days of good food, stable caretakers, a regular schedule, clean and safe living conditions, and no violence worked wonders. Tony’s apparent psychosis resolved without the use of antipsychotic medication.
When I sat down and started to talk with Tony, I didn’t want to interrogate him. Playing a hunch, I asked him if he believed in Jesus.
“Oh, yes! Doesn’t everybody believe in Jesus? Jesus gonna save us all. I love Jesus.”
So we were off to the races. Pretty soon we’d made up a game that we called the Jesus Game. Tony and I would take turns playing Jesus, and we’d ask Jesus questions.
Tony asked me to play Jesus first. I said OK. So Tony asked me, “Jesus, what you do when someone disses your mama?”
Good question. My answer: “I’d say, ‘Why do you say that? What did my mama ever do to you?’ ” We were sitting in my office when we played this game, usually on the floor, or sometimes we’d be outside on a bench in the park across Fenwood Road from MMHC.
“But Jesus, your mama be soooo ugly, she’s so ugly she scare the pigs. What you say to that, Jesus?”
“I say, ‘Why you want to dis my mama like that? She never says nothing bad about you.’ ”
“Jesus, I think you’re nothing but chickenshit. You let me dis your mama like that and you got nothing to say but this chickenshit jive?”
Time for me to get to the point. “I don’t know why you want to talk like this to me. Did somebody sometime hurt you real bad?”
Tony said, “Now it’s my turn. I play Jesus!”
“OK,” I agreed. “So, Jesus, what would you do if I made you really angry at me?”
“I would throw down a thousand poisonous snakes to wrap all around you and bite you and kill you, that’s what I would do, and then I would shoot you a hundred times and I would throw you into the fiery furnace.”
“Tony, this is Dr. Hallowell speaking. That’s not the way this game is supposed to go. You’re supposed to make up ways for Jesus to get angry that do not involve hurting people, let alone throwing them into the fiery furnace. Where’d you learn about the fiery furnace, anyway?”
“In church they always be talking about shit like that. How we all gonna burn if we don’t be good.”
“But how about if you try to play Jesus and think of ways of sticking up for your mama without killing anybody?” I asked. “Jesus told people to love each other, didn’t he?”
“Yes, he did.”
“OK, so now you play Jesus,” I said.
“OK,” Tony said.
“Jesus,” I started in again, “so, I think your mama is way ugly.”
“Well, I think I am just gonna have to love you for saying that because to tell you the truth she is pretty ugly.” Tony laughed a long hoot of a laugh. “She’s real ugly!”
“Do you love her anyway?”
“Shit, course I love my mama. Except when she whip me. Then I don’t love her.”
“She whip you much?”
“No, not as much as I probably need, because she’s so fat she can’t catch me.”
“Why you think you need to be whipped?” All my years in New Orleans had trained me in the culture of African American parenting, which usually did include what they called whipping, but it wasn’t nearly as severe or brutal as what white people imagine whipping to be, at least not in the hands of most mothers.
“Because I can be bad,” Tony said. “I tried to hurt my sister and my mama both.”
“Why did you do that?”
“Because they make me mad. I wanted them to leave me alone and they wouldn’t.”
“You wanna go back to playing Jesus?” I asked.
“OK,” Tony said.
“Jesus, what could you have done yesterday when you were mad at your sister and mama besides trying to hurt them?”
“I could’ve turned the other cheek.”
“Jesus, that’s one of your favorite sayings, but could you think of something else you could do when you feel angry?”
“You mean besides set them on fire?” Tony said, laughing.
“Yes. Besides that. You gotta agree, Jesus, that’s not very loving, setting someone on fire.”
“It sure ain’t,” Tony said, “but it sure do feel good!”
“Jesus! That’s not what you would say, I don’t think.”
“OK, so what does Jesus do when he gets mad? I know. He preaches. He tells stories. He overturns tables.” Tony proudly folded his arms.
“Wow, you do know your Bible.”
“Well, Doc, what you expect? My mama drag me to church all the time.”
While I was getting to know Tony, I was also learning about ADD. In addition to the many other diagnoses Tony qualified for, ADD was on the list. The hallmark triad of symptoms that defined ADD Tony had for sure: distractibility, impulsivity, and hyperactivity.
The psych testing that had been done a few days after Tony was admitted, once his psychosis had subsided, did not mention ADD, but that could have been because other concerns were more prominent. For example, his IQ was 69, which is borderline retarded.
I wanted to try Tony on a medication I had only read about but never given to a patient, called methylphenidate, or Ritalin. I talked it over with Jules Bemporad, the head of the division of child psychiatry at MMHC during my training, and he agreed it was worth a try.
Next, I needed to get Tony’s mother’s permission and also run it by the nurses and other staff on the unit. Giving any medication to a child, especially one as young as eight, was a big deal in 1981, and required many discussions, team meetings, chart reviews, second opinions, parent sessions, discussions with the child, and, in general, prolonged preparation.
Tony’s mom sat in my office holding a Dixie cup on her lap that she spat into while we talked, because she had bronchitis.
We talked about this and that for a while. I at least wanted her to get comfortable with me as a person, not just a doctor.
“Where are your people from?” I asked, after telling her I grew up on Cape Cod.
“Loosiana,” she said. “Nawlins.”
Pay dirt. “I went to medical school at Tulane.”
“For real?” she asked. “My sister’s babies were born at Charity.”
I wanted to ask her if one of them might have been named Fenway Park but didn’t. “No kidding. That’s amazing. I did my OB rotation at Charity. That was five years ago.”
“Her babies be older than that. But don’t that beat all, you bein’ from Nawlins, or at least gone to school down there. You like red beans?”
“I love them! I can even make them. Not as good as down there, but pretty good, if I do say so myself.”
“Well, Doc, I’m gonna make you some red beans and you can tell me which you likes better.’’
“I’d love that,” I replied. “So how do you think Tony is doing?”
“How you think he’s doing?”
“A lot better than the day he came in.”
“That’s good,” she said, and spat into her cup.
“He’s a smart kid,” I said.
“How do you know that?”
“Just talking with him. He understands things quickly.”
She smiled. “Yes, he does. But then why he be so bad? I watch him every day, and I try to keep him away from the gangs.”
“You do a great job. And you’ve given him a real solid foundation in Christianity.”
“I do my best. I’d be lost without the Lord so I try to fill Tony with as much of that as I can while I’m still able to.”
“I do have one idea. How we might be able to help him even more. He has a condition called attention deficit disorder, and there’s a medication that can help with that.”
“Whatever you say, Doc,” Tony’s mom said. Nobody agrees to medication that quickly, not even now in 2017, and certainly not then, in 1981, unless they trust you. All my training in politeness really came in handy as a psychiatrist. “What’s this medicine do?” she asked.
“If it works, it will help him focus his mind better and control his impulsive behavior.”
“Let’s hope it works,” she said, with a combination of hope and desperation in her voice.
It took me
weeks to persuade the nurses and other staff on the unit to give Tony a trial of Ritalin. Tony was up for it right away (“Whatever you say” were his exact words), but the staff, who were very invested in the kids on the unit and felt extremely protective of them, raised the usual objections: “Why can’t we just let Tony be Tony? Why do we have to drug him? Aren’t these medications dangerous? How do we know what the medication will do?”
Once I’d addressed all of their concerns sufficiently that no one was strongly opposed, we gave Tony 10 milligrams of Ritalin, a small dose. Then we watched and waited.
The medication takes effect in about twenty minutes. Tony did not dramatically change, but staff comments later indicated he was better focused, less distracted, and less impulsive. He was also able to do better in the school on the unit. He suffered no side effects. The Ritalin didn’t even cut his appetite, which it usually does.
The trial of medication seemed a success, but to get some objective feedback I asked the neuropsychologist to repeat the testing she’d done just after his admission.
Tony was on Ritalin when he had the second testing. His IQ now measured 140—a stunning increase, more than double his original score. In my thirty-six years since then, I’ve never seen a jump in IQ even close to that. I’ve told the story to neuropsychologists and some of them tell me it’s impossible, I must be wrong, or the testing was flawed. But what I do know for sure is that Tony was able to use his brain far more effectively after he started his medication.
Tony also taught me how dependent your IQ is on your state of mind. When first tested, Tony was just coming out of a psychotic state, he’d been recently traumatized, he’d had little sleep, and, of course, he had undiagnosed and untreated ADD. If you can’t pay attention, you will score spuriously low on all tests, including IQ.
I would work with Tony and his mom for two years, until I completed my fellowship. Tony became curious about me and my childhood. “Where’d you grow up?” he asked me.
“Mostly in a town called Chatham, on Cape Cod.”
“Were you ever bad when you were a kid, I mean bad like me?” he asked.
Because I Come from a Crazy Family Page 32
