by Samuel Shem
Yet she herself remained hidden. A woman from a poor Irish family, she’d worked her way through secretarial school and had become an assistant to the director of admissions at Harvard, over an hour’s commute away. Institutions like Harvard always have a warmhearted type on the front lines, protecting the hard-hearted higher-ups, and Mary Megan was it in Admissions. She had had her share of suffering: married at forty, she gave birth to a baby with Down syndrome. Now a six-year-old, the boy was severely disabled. Mary Megan was a hefty woman, but she had lost her appetite, begun eating very little, and lost a great deal of weight. People said, mistakenly, that she ‘looked good.’ Two weeks before, she had completely snapped. She was picked up by the state police on the side of the interstate, weeping hysterically, threatening to throw herself into the traffic. As they were coming home from vacation, the family’s luggage had blown off the roof rack and her six-year-old’s new parka had flown away and re-appeared crucified on the front grille of a trailing ten-wheeler. Since then she’d been actively suicidal. But something didn’t make sense. Why should luggage falling off a car and a parka on the front of a truck plunge a fine, by-all-accounts cheerful woman with lots of friends at work and home into suicidal despair? No-one, not even Ike White, had been able to find out.
‘OK!’ Errol said as we sat down, before Mary Megan was brought in. ‘Let’s go. Win and I have read the chart, so we all know the case. First, diagnosis. It’s absolutely clear this gal is a BPO with Ano—’
‘First,’ Malik said, ‘we talk with her.’
Errol’s jaw dropped, as if this were incredible, for a doctor to actually talk with a patient.
Mary Megan Scorato came in. Her freckled milky complexion was marred by dark bags under her eyes and slack skin around her mouth. The edges of her lips turned down, as if she were on the verge of tears. Her auburn hair was unwashed and halfheartedly in a bun, ends escaping out and hanging despondently down, ends she didn’t brush out of her eyes. Her clothes, usually neat and clean and perky in the way that an old-fashioned good mother’s kitchen clothes are perky, were rumpled and too big for her thinning body. She nodded to Errol, Win, Malik, and me and sat down. Malik explained that we would talk.
‘This morning I wrote a little poem for this conference,’ she said.
‘What meds are you on, sweetheart?’ Errol asked.
‘Dr White was so kind and good, I wrote a poem.’
‘What meds worked best in the past, gal?’ Errol asked.
It went on like that, Errol talking drugs and Mary Megan talking poetry. Mary Megan got more and more subdued. I felt for her. Finally Malik said, ‘You OK, Mary?’
‘No I am not! I came here to read my poem for Doctor—’
‘What about anticonvulsants, honey?’ Errol asked.
Mary Megan stared at him and then took a green piece of glass out of her sleeve and held it to her wrist. ‘Let me read my poem or I’ll cut myself!’ Her thin cheeks made her eyes seem huge.
‘Read,’ Malik said. ‘We’ll listen.’ Mary read her poem, ending with:
‘We all imagined his hesitant, stammering manner Merely concealed his heart’s strong core,
But he had his misery, his hesitant stammering manner, And nothing more.’
Stillness. She’d gotten him exactly right. Errol and Win kept rocking in their chairs, but said nothing. Mary handed the piece of glass to Malik.
‘Beautiful,’ Malik said, ‘and true. Can I ask you a few questions?’
‘Yes. If you can be kind, like Dr White.’
‘I’ll try,’ Malik said. He talked with her for a while, and then the strangest thing happened. Later I couldn’t recall how it came about, but after just a few minutes of their talking, talking as if they were old friends meeting after a long time, talking about her Down syndrome son and the parka crucified on the truck, Malik asked her something that seemed completely bizarre: ‘Tell me about your other son.’
Mary Megan sat up in shock, her eyes wide. ‘My other …?’
‘Yes. The one you lost.’ I had no idea what he meant. Mary Megan had said nothing about another son. I felt a kind of ‘click.’ I waited.
‘Oh God!’ she said, and began to weep softly, and on her tears rode a story none of us had ever heard from her. Thirty-one years ago, when she was seventeen, she’d been forced into sex with a neighbor and gotten pregnant. She’d told no-one but her mother, who demanded that she give the baby up for adoption. Finally Mary agreed, on one condition: that the Clarissan nuns taking the baby let her see it just once. The Mother Superior agreed. She gave birth to a boy. The nuns never let her see it. Every year, every single year on his birthday, she would think of that baby boy and wonder where he was, and what his life had become. ‘A year and a month ago,’ she said now, ‘on his thirtieth birthday, the phone rang. I picked it up. A man’s voice asked, “Is this Mary Megan O’Toole?” I knew at once. My heart seemed to tear loose inside me. I said, “Yes it ’tis.” “Well … I am your baby boy.”’ She wept frantically, searching for tissues. Malik handed her a box. Calming down, she went on, ‘We met a few days later, and … he said he wanted to meet just the once, no more. I told no-one, no-one knows this, no one a’tall, not even my dear husband Joey. I never even told poor Dr White. I was OK for a year, but then, this year, without him, when that day came ’round … I could not go on … I couldn’t even eat.’
‘Anniversaries are killers,’ Malik said. ‘You had an “anniversary reaction” – it’s totally normal. And why didn’t you tell Dr White?’
‘He seemed too … vulnerable? And he didn’t ask, like you did.’
‘You feel OK about telling us?’
‘I do. You have a kind face. Thank you.’
‘Now that it’s out, we can help you to heal the wound.’
She wept again, quietly. I felt moved, awed even, by Malik’s way: so simple, so there with her. She sniffled. ‘That would be fine. Thanks.’
Mary Megan left, shutting the door quietly behind her.
‘OK good great,’ Errol said loudly. ‘Now let’s do some real work!’
He and Win then discussed the ‘case,’ fitting it brilliantly to Borderline Theory, concluding that the diagnosis was BPO with A and B – Anorexia and Bulimia – even though Mary had explicitly denied previous anorexia or bulimic vomiting. And wouldn’t you know it but BPO with A and B was a particular diagnosis Errol just happened to be the world expert in! Not only that, but by sheer coincidence he was also the world expert in the drug to treat it! ‘The treatment of choice,’ he said, ‘is my experimental drug amyoxetine – brand name Placedon. Brought it back from Bangkok – in my backpack. Placedon makes Prozac look like popcorn. We may need to add my other experimental drug, Zephyrill.’ While these names were enticing, as if, if you did these drugs, you’d be partaking in an encounter with two of Babar’s lost children, I was appalled at this, a diagnosis and treatment totally at odds with her obvious and what seemed to me normal grief.
‘The woman is going through a normal grief reaction,’ Malik said. ‘If we can keep her off drugs, she’ll pull together just fine.’
‘This is for the benefit of the new residents,’ Errol said, glancing at me and Win. ‘There’s never once been a controlled experiment that showed that talking to patients does any good at all. Any effect is placebo effect. You residents shouldn’t waste your time learning how to do this mumbo-jumbo, ’cause there’s no “it” to do. So Malik got her to tell a story, so what? Won’t help. Like pissing in the ocean. There are no “psychosocial” factors in mental illness. If it’s mental illness, it’s biochemical, and vice versa. Save her a lot of grief – give her Placedon.’
‘Thanks for sharing, Errol,’ Malik said, ‘and now go fuck yourself.’
‘So,’ Errol went on, as if Malik hadn’t said what he had said, ‘to get these experimental medications, she has to be in our new research study.’ He took out a lavender form and got up. ‘I’ll get her informed consent.’
‘She refuses all d
rugs,’ Malik said, rising. ‘Thanks for stopping by.’
‘Don’t worry, we’ll get her to sign.’
‘She won’t talk to you, guaranteed.’
‘We’ll get husband Joey to sign.’
‘Not without permission.’
‘She’s not competent to give permission. She’s a borderline!’
‘And,’ said Win Winthrop, ‘bulimic. She deserves a trial of Placedon.’
‘After she’s on it, we’ll get some of her blood,’ Errol said. ‘When her level’s in the therapeutic window, she will be competent, and then she can decide rationally about going off Placedon no problem thanks.’
Malik picked up Mary Megan’s chart and read aloud as he wrote, ‘“Patient is mentally competent. Patient refuses all drugs.”’
Red-faced, Errol rose and said, ‘Know what your problem is, Malik?’
‘Maybe that I think you’re a neo-Nazi?’
‘Your problem is you’re nuts and you should be on medication!’ They hurried out.
‘Wait!’ Malik shouted. ‘When are you gonna study drug compliance?’ He turned to me. ‘Know what they don’t do?’ I asked what. ‘Sports! C’mon.’
In the nursing station, as he changed into shorts for his morning run, Malik said, ‘Don’t get me wrong, I’m not against using medication. I use it, if it’s right to use. But all the studies of compliance show that patients don’t take their drugs fifty percent of the time, and that the only reason they do is if they have a good relationship with their doctor. And guys like Errol are terrible at relationship. Which is one of the two reasons they specialize in drugs. Walk me out.’ I followed him outside.
‘What’s the other?’ I asked, squinting at him in the bright sun.
‘Money. Drug-therapy guys like Errol see six patients an hour, at seventy dollars a pop: four hundred and twenty dollars an hour. Talk-therapy guys see one an hour, at a hundred bucks.’ He stretched his quads, pulling a bent leg up behind his back so that, with those amber lenses astraddle his beak nose, he looked like a wise, hip stork. ‘Talk therapy is dying. The drug cowboys are taking over. They use drugs to stay away from being with people. It’s easier than being human with that kind of suffering. Other than drugs, the only way to make a living as a shrink is to write some bullshit self-help book. I’m thinking of writing one called Anorexia Digest.’
‘But how did you know, I mean about the other son?’
‘Dunno. When she talked about that parka, crucified, I picked up somethin’, like “lost son.” So I took a shot, got lucky. Sometimes people don’t know that on anniversaries they crash. Just to name it helps a lot.’
‘It’s so sad! Every year, for thirty years, on that day, she’s wondering where he is? It blows me away.’
‘Yeah. Ike’s suicide for her, for all of us, is a big “Fuck you!”’ He sighed. ‘So now you see all the bullshitology around “diagnosis.”’
‘Isn’t diagnosis important?’
‘In psychiatry, diagnosis comes last.’
I felt confused and overwhelmed. Everything this fanatic was telling me was the opposite of what I’d been taught about psychiatry before.
‘Here, sit,’ Malik said. ‘Listen up.’ I sat on the lush, close-cropped grass, staring at Malik’s tank top, on which two lambs were holding hands over their heads in triumph, and the acronym LAMBS. ‘This is a BPO ward. But check out the diagnoses: BPO with A – Anorexia; BPO with B – Bulimia; BPO with C – Catatonia; BPO with D – Depression; BPO with M – Mushrooms.’
‘Mushrooms?’
‘Just checking. So Blair Heiler keeps trying to fit people into BPO, but they won’t fit. So he keeps adding letters. One of these days he’ll admit an adolescent with BPO with Z – Zits!’
‘Why does Heiler try to fit people into diagnoses?’
‘Money and fame. He’s a protégé of Lloyal von Nott, world expert in money. He gets Lloyal to give him a ward for BPO. He gets drug money to study the Krotkey Factors to diagnose BPO. He finds that BPOs fit the factors! Quite a coincidence, eh? He gets more patients, with more BPO. Becomes world expert in BPO. Fame, money, climbing the greasy pole of academia. Heiler’s in a catfight with his rivals at McLean Hospital to corner the market on BPO. Meanwhile he terrorizes these patients – which makes ’em act like BPOs! He publishes, they perish. Lotta suicides on his ward. Which is another Krotkey Factor: BPO with SS – Successful Suicide. And BPOs don’t even exist. They’re just people, right? We coulda got any diagnosis we wanted outta Mary Megan, depending on which diagnosis the world expert we called in was world expert in. In psychiatry, diagnosis comes last.’
‘What comes first?’
He put a hand on my shoulder. ‘Roy, you’re gonna think this is crazy. In psychiatry, first comes treatment, then comes diagnosis.’
‘That is crazy,’ I said. ‘It goes against hundreds of years of medical science.’
‘You think this is a science?’ he asked.
I didn’t know what to say. For a while I stared at a duck carving lines on the still lake. Finally I said, ‘I don’t know, Malik. You sound pretty cynical.’
‘Think of Mary Megan, her face when she took out that piece of glass. That was the face of terror, right?’
‘But this, you, what you’re saying, it’s nothing like my month with Ike. This is not what I expected.’
‘Good. That’s the first real thing you said. Listen up: all you gotta do to learn here is keep your eyes open, your fly zipped, your feelings up front, and ask for help. Don’t read any bullshit articles. Don’t read, do. See. Feel. Do. And see everything in Misery in terms of Ike’s suicide.’ He turned on his Walkman. ‘Aerosmith’s “Amazing”!’ he cried. ‘Steven Tyler is my God!’ He sang along and started to plug the earphones in.
‘Wait,’ I said. He waited. ‘Why are all these experts denying their feelings about Ike?’
‘’Cause they mistake having no feelings for being smart.’ He trotted off.
‘I’m sorry if I sounded angry yesterday when you called to set up our appointment,’ Christine was saying a few minutes later as we sat in my office in the attic of Toshiba, listening to the phwop phwop of tennis balls being hit three floors below. ‘I was feeling really bummed, and I kind of said all the wrong things.’
She was sitting on the edge of her chair, her brown eyes fixed on mine. As I met them, she looked down into her lap. She was a thin thirty-one-year-old woman with hair the bleached blond of Madonna cut smartly mid-length, freckled white skin, a button nose, and small lips tense with dark scarlet lipstick, matching her dark scarlet nails. The white part in her scalp gleamed, a furrow between dark roots. She was all in black, as if in mourning – black sleeveless silk blouse with hints of black lace bra, short black skirt, the white of her kneecaps highlighting the pattern of black flowers of her black panty hose. Her perfume was musky. I had a hit of being attracted to her – and immediately felt it was wrong. I focused on putting it out of my mind.
‘So what do you think about it, Dr Basch?’
She was leaning forward intently, curious to hear my reaction to what she’d said. With a creeping sense of terror I realized it was a little difficult for me to tell her my reaction to what she’d said since I’d been trying to put the sensual part of all this black and fake blond out of my mind and hadn’t heard a single word. Glancing into my lap at my wristwatch – and trying to conceal my glancing from her – I saw that four minutes had passed. I’d missed hearing an important thing she’d said, and because it was important, I couldn’t admit I hadn’t heard it. Could I ask her to repeat it? Suppose it was that at her mother’s funeral she’d been gang-banged by fourteen Hell’s Angels and left for dead, and I respond with, ‘Uh, did you say something, Christine?’ She was staring at me expectantly. In desperation I found myself saying, ‘Do you mind if I ask you two proverbs?’
‘Proverbs? I … I guess not.’
‘What do people mean when they say, “A rolling stone gathers no moss”?’
She s
at back. ‘If I do just keep on dating and don’t find a guy – I’ll keep on going in my career with IBM and not have a family – not have that white picket fence and dog and babies – and just be a career woman?’
‘Um-hmm. And, “People who live in glass houses shouldn’t throw stones”?’
‘OK,’ she said, smiling guiltily, as if I’d had some incredible insight in choosing this particular proverb, ‘I’ll tell you about my mom.’
Her mom, the wife of an Indiana farmer, knew how to slaughter animals and fix trucks. The mother/daughter relationship was a real love/hater. Somehow talking about Mom led back to her last boyfriend, Rocco. She said, ‘So I called Misery because of trouble with men.’
‘What’s the trouble with men?’
‘You tell me! You’re one of ’em. What goes on in there with you? Do men feel? If so how, and what? What happens between receiving a message and sending back your response?’ I stared at her, unable to send back a response. ‘See?’ she said, shaking her head in dismay. ‘I read all the books. Y’know the Women Who Run with Wolves? Well, I’m a woman who ran to wolves, ’n’ now I like run from wolves! The sex has always been great, but the talk? Pitiful. Ever since Rocco walked out on me I’ve been drinking more and smoking more dope and getting suicidal.’ She glanced down. I peeked at my watch, figuring time was up. Only another ten minutes had passed? Half an hour to go? I looked up. She was staring at me.
‘Is the session over?’ She fluffed her blond hair, releasing scent.
‘My watch must’ve stopped.’
‘Eleven twenty-one.’ She uncrossed and recrossed her legs – slwish slwish went the rows of black flowers. Leaning forward and looking at me intently, she asked, ‘What about you? Where’d you go to school?’
Feeling pressured, I said, as blankly as possible, ‘Around here.’
