Falling Into the Fire: A Psychiatrist's Encounters with the Mind in Crisis

by Montross, Christine

  When I finally walk in the door of our house, Deborah exhales. She looks pale but has a forced smile on her face that I recognize from turbulence on planes—she is terrified, but she doesn’t want the children to be. And it has worked. They run up to me shrieking about what fun it is to be “camping” in the basement, and how cool the sounds of the wind are, and that Mommy has given them each their own flashlight to use, isn’t that amazing?

  It is, I say, and pull Deborah close to me. The rest of the day, despite the unrelenting gusts, the cracking of limbs, the hammer of rain, she is not scared. She swears there was something exceptional about the wind’s strength while I was gone. That may be. Or else there may be a way in which it is scarier to face a threat alone, without someone there to see what you are experiencing, to comfort, to understand.

  When the winds finally relent a bit and the radio says the worst has passed, we step outside. The ground is entirely green with leaf litter, and branches are down as far as the eye can see. Our house is unscathed, but our neighbors, Jim and Wendy, aren’t so lucky. A huge tree from their front yard has been uprooted and has landed on their roof. Another has fallen across their driveway and is resting on their car. That evening we go for a walk with the kids to look around. Jim is standing beside the tree.

  “We can’t believe this, Jim. We’re so sorry!” Deborah says. “What a nightmare for you.”

  “Oh, this?” Jim smiles. “Hey, come on in, you guys.” He gestures for us to follow him, and as we duck beneath the branches hanging over his front door, we see that their home is packed full of our neighbors. In an instant, someone hands me a cup of wine and someone else gives our kids plates of mac and cheese. A generator hums in the backyard, and the kitchen counter is covered in food. We look at Wendy with confusion.

  “I’m from New Orleans.” She beams. “When this kind of thing happens, you throw a party. That’s how you move forward.” Deborah and I look at each other in shock. “Do y’all want some chili?” Wendy asks.

  In the hours after the hurricane, Narragansett Bay is transformed. Mighty, loping swells crash in the shallows, scraping the beach and carving great craters in the sand. Along the beach far into the distance, sea stars of every size have been thrown up by the waves. They are all dead, or dying. I don’t know why. Were I seeing this body of water for the first time, I would be unable to imagine it as placid as it was the day that Welly and I paddled alongside each other.

  The circumstances of the world shift without explanation or warning. Why do some of us meet difficulty with despair and others do so with fortitude? Who can comfort us when we are scared? Whom do we gather around us when darkness descends and the trees fall? What if a tragedy in a person’s life cannot be so plainly seen by others? What if it cannot be understood at all?

  (CHAPTER THREE)

  Your Drugs Take Away the Love

  I remember when I lost my mind

  There was something so pleasant about that place

  Even your emotions have an echo in so much space

  And when you’re out there without care

  Yeah, I was out of touch

  But it wasn’t because I didn’t know enough

  I just knew too much.

  Does that make me crazy?

  Possibly.

  —Gnarls Barkley, “Crazy”

  Late nights in the psychiatric emergency room, it’s not unusual to meet someone who claims to be Jesus. The night that I first saw Colin, the patients had been relatively ordinary by psych-ER standards: a demented elderly man who kept asking me to lie down in his reclining chair with him, a fifty-something-year-old woman withdrawing from alcohol, a forty-five-year-old lawyer and father of two who had been so depressed that he wanted to drive his car off a bridge. I was working on the inpatient wards at the time, but I had picked up the night shift in the ER because the hospital needed extra staffing.

  I was typing my assessment of the suicidal lawyer when Colin wandered through the metal detector, past the blood-pressure cuff and Breathalyzer, and up to the doorway of the ER’s administrative area, where he stood staring straight at me. At first I felt the sensation of eyes on me. Then, when I turned to find the source of the feeling, I saw Colin: a young man, maybe in his early twenties. His skin was tanned. He had long, tousled, light brown hair that had been sun-bleached to blond in streaks, and he was wearing an embroidered white tunic smudged with dirt. Unlike the many patients I encountered who claimed to be Jesus, this guy actually looked the part.

  When my own glance met his stare, there was no self-conscious shift of his gaze, no quick turn away. Instead his eyes continued to bore straight into mine. His face was expressionless and haunting. Eventually one of the security guards gently guided him back into the waiting area. I finished typing and began to interview another patient. The next time I walked through the waiting area, Colin was gone.

  Frequently when I leave a shift in the ER, cases and clinical questions from the night linger in my mind. Did I double-check the lab work on the demented patient to rule out a delirium-inducing infection? Was the woman who had been cutting the insides of her thighs with a razor blade really safe enough to go home? This night the image of Colin’s fixed stare stayed with me as I left the hospital.

  In general, psychiatrists don’t scare easy. We become accustomed to patients telling us that their thoughts will kill us as they’ve killed nations, that they know we are part of a conspiracy to place satellites in their houses and that we will have to be brought to justice. Sometimes I’ve been uncomfortable enough to bring a security guard into the room with me—as when an enormous man who had spent a decade incarcerated for murder was released from prison, caught a bus straight to the psychiatric hospital, and told me that the red eye that had commanded him to kill was hovering around the room in which he and I were talking. But more typically these stories are the ones we share with our colleagues whose shifts begin as ours end and who ask how the night was. Nonetheless, something about Colin’s silent intensity had unnerved me, and, not knowing whether he’d been admitted or released, I found myself skittishly looking around, half expecting to see him as I walked to my car to drive home.

  The next morning I went into the locked inpatient ward where I worked during the days and gathered my patients’ charts. Because patient stays are short in the era of managed, and largely outpatient, mental-health care, on any given day my stack of charts included a fair number of patients whose names were new to me. Other charts belonged to terribly familiar faces: patients whose telling “episode number,” designating how many times they had previously been hospitalized, could easily be more than twice their age. (The most recent of these examples that I encountered—a sixty-five-year-old man caught in a chronic cycle of homelessness and suicidality—was on his 246th episode.)

  On the unit I’d typically situate myself with the charts in one of the small private interview rooms. While a medical student would go rouse a patient from her bed and usher her into the room to talk, I’d skim quickly over the evaluation done at admission so I would have an idea of the circumstances that had brought the patient to the point of psychiatric hospitalization.

  This morning was no different. The med student said, “I’ll start with Room 32B,” and walked out. I picked up the corresponding chart, flipped it open, and saw the three-inch-by-three-inch admission photograph of Colin, eyes staring into the camera as intently as he’d been staring into the administrative work space of the ER, just as intently as he’d been staring at me.

  Late nights during residency training—or early mornings after we’d worked twelve, twenty-four, even thirty hours straight—my fellow residents and I would sometimes make a game of those snapshots. They’re universally grainy and off center, taken by a camera attached to the hospital’s intake computer, but the shared belief of all psychiatric residents is that the further along one gets in one’s training, the more likely one is to be able to de
termine a patient’s precise diagnosis by merely looking at the picture. It’s a ridiculous assertion, of course, which elucidates the stereotypes we develop as doctors more than it does any consistently discernible physical traits of mental illness. Still, we play the game.

  Those admission photos—and the assumptions we make about them—are a perfect example of how certain realms of medicine can come to be devoid of empathy. Countless factors in medical education contribute to allowing a young doctor’s empathy to fade. Residents may legally work as many as eighty hours per week; that kind of ongoing sleep deprivation in the midst of such emotionally demanding work can turn even the most humane doctor into an inattentive grouch. As doctors, we must also find ways to protect ourselves from the aspects of our patients’ conditions that upset us, so that we are not overcome by the onslaught of suffering in which we practice. Sometimes we do this in healthy ways—we talk with loved ones or therapists, we run or play music or cook, we dwell on the gratitude we have for our own relatively healthy lives. Other times we rely too heavily on alcohol, or we immerse ourselves entirely in work to the exclusion of every other element of our lives, or we burn out, or we quit. Still other times we find immature but relatively harmless means of diversion. Like the narratives we invent about our patients’ photographs.

  When I see Colin’s snapshot at the front of his chart, I hear in my mind an imagined banter between residents:

  “On the run from the Branch Davidians’ compound. And angry about the government raid, which he feels interfered with his ascension to join the Hale-Bopp comet or whatever bullshit that was,” one resident would begin.

  “Ooooh, that’s good,” the other would reply. “Diagnosis?”

  “He’s all Axis I. Delusional disorder. Maybe with some intermittent explosive disorder mixed in to account for the uncontrollable anger. You want to agree and give up now, or do you have a better theory?”

  “Nope. Listen to this: first psychotic break, exacerbated by heavy pot use and occasional assorted hallucinogens. Mostly ’shrooms. He thinks he’s Jesus and is receiving personal messages from God. He believes he can see through to our souls, and he doesn’t like what he sees.”

  “Okay, diagnosis?”

  “Too soon to say. He’ll get Axis I: Psychosis NOS. And then in six months, when it’s lasted long enough to meet criteria, he’ll be schizophrenic, like some uncle on his mom’s side who lived in the hospital for thirty years.”

  And then, to lay any snap judgments to rest, I read Colin’s emergency-room evaluation.

  “Patient’s Chief Complaint: ‘There is a good energy here.’ History of the Present Illness: Patient is a twenty-three-year-old male who was brought to the hospital by his girlfriend secondary to an increase in bizarre behavior. The patient eloped from the emergency department and was brought back by the police. Patient’s girlfriend describes odd behavior at home, including walking backward and walking in a circle before picking an item up, both of which the patient explains as actions that ‘untrack energy.’ The patient has also urinated in a Coke bottle and says he is ‘sleeping without sleeping.’ Patient has refused meds from his psychiatrist, whom he has seen twice weekly for the past six weeks. He says he is having trouble expressing his thoughts and that ‘I have a lot of things I need to accomplish.’ Patient’s parents arrived from Chicago after they were called by patient’s girlfriend. They report that they believe he has ‘had a spiritual awakening and wants to be a better person,’ but they agree that his behavior is concerning.” Finally, on the bottom of the page, the doctor who had done the evaluation had scrawled a quote from Colin: “I am functioning normally. I don’t know why people think I’m not.”

  The medical student walked in and gestured for Colin—still dressed in his stained tunic—to follow. He did, and stared at me again with the familiar gaze from the night before. Then he stared with the same intensity at the empty chair to my left, then at the locked window with no shade, and finally at the Monet poster encased in plastic and bolted to the wall. When asked to, he sat. And smiled.

  “Hi Colin, I’m Dr. Montross,” I said, “and you’ve already met Vijay, the medical student on our team. If it’s okay with you, I’m going to let Vijay start, and then I might pipe in at the end with a few more questions. How does that sound?”

  “Sure,” replied Colin. And then to Vijay, he said, “Welcome.” I could tell that the student wasn’t exactly sure how to respond.

  “Uh . . . thanks,” Vijay stammered. “Why don’t we start by hearing why it is that you came to the hospital?”

  Colin sat quietly for what was probably a minute but seemed like much more. Then, right when I was on the verge of repeating Vijay’s question, the silence broke.

  “I’m having trouble communicating my life journey to others,” Colin said.

  “Tell me what you mean by that,” Vijay asked, leaning forward in his chair.

  “Well,” Colin responded, smiling, “I think you know this.”

  Vijay smiled back, perplexed, then shrugged.

  Colin continued. “The most important thing for all of us to know is that life is joy. I’m experiencing a soulful happiness, and I think it is hard for everyone to comprehend.”

  As the interview went on, I jotted my own rough clinical assessment for the file: “Wide-eyed, malodorous young man in tunic, unshaven. Speech is slow. Thought process is disorganized and circumstantial; content is grandiose. Patient denies auditory or visual hallucinations but does endorse elated mood. Affect is expansive. Insight and judgment are poor, as evidenced by the fact that patient does not see the need for help.”

  Vijay finished gathering some final information. Colin had graduated from a prestigious college with an art degree; his senior thesis had been a series of huge metal sculptures. Since college he had been employed on and off as a metalworker on construction sites to support his artwork. He had recently quit to spend a month following a woman called Amma the Hugging Saint through the western mountains of the United States. Amma’s doctrine is love, he told me. She feels love for all people, and she provides comfort to those who suffer by hugging and blessing them. During the time he was with Amma, Colin had smoked pot and used some hallucinogens, but he said there had been no drug use for a month or more, and his clean toxicology screen from admission supported this claim.

  I had a list of potential diagnoses in mind. My first thought had been drugs, but given the results of the toxicology screen, that etiology was rather convincingly out. There was a remote chance that his symptoms were the result of exposure to some volatile substance in his metalwork, but his blood tests weren’t indicative of any kind of dangerous solvent or heavy-metal exposure. The other two options were either bipolar mania or a primary psychotic disorder like schizophrenia. In both of those conditions, medication would be the treatment of choice for an acute flare of symptoms like this one.

  “Colin, thank you so much for sharing your thoughts with us,” I said. “I know you’ve felt misunderstood recently, so we’re going to work very hard to understand what you’re experiencing.” This was true, but it was also an attempt to navigate the complexities of trying to treat someone exhibiting psychotic symptoms without reaching too far into paternalism or, worse, trickery. Frequently patients are reticent to take medication. Sometimes their reasons are good and sound ones. Sometimes their fears are paranoid, their beliefs are illogical, or their minds simply cannot process the information fully enough to make an informed decision. I believed that medication could help Colin, and as a result I tried to convince him to give it a try. I thought my best strategy was to talk to him about it in his own terms. “We have some medicines that I think could help you communicate that experience more clearly.”

  Colin looked at me quizzically. “Why would I take medicine?” he asked. “I’m in love with the feeling I have right now. This joy is better than any drugs.”

  And this is how our conversations
went that morning and for the next few mornings. The nursing notes in the chart were similar from one shift to the next: “Patient is pleasant. Dreamy and detached. He continues to pace on the unit or stand in place until redirected. Refusing meds.” A few days in, during our morning session, Colin began asking to leave.

  “It’s not that there isn’t plenty to love in here,” he said, gesturing toward a metal filing cabinet and then an institutional plastic chair. “But I’m not sure how much longer this place needs me.” And here is where things for Colin—and for me—became a good deal more complicated than they already were.

  Colin had been brought into the hospital involuntarily. In every state in America, a physician may commit a patient to psychiatric care against his will if the doctor believes there is an imminent danger that the patient will harm himself or others. The work of Dr. Paul Christopher, my colleague at Brown, has called attention to the fact that the consequences of hospitalizing someone against his will vary widely from one state to the next. In Rhode Island, where we practice, once a patient is involuntarily committed, he can be hospitalized against his will for up to ten days before a court hearing is mandated. Many states allow fewer days, but some allow far more. In West Virginia a patient may be held against his will for only one day; in Georgia no hearing is required until twenty days of inpatient hospitalization have passed.

  Plus, even in the absence of imminent danger, many states allow a physician to commit a patient against his will if he is classified as “gravely disabled.” In 1975 the Supreme Court asserted in O’Connor v. Donaldson that the inability to care for oneself does not sufficiently demonstrate danger unless survival is at stake. “A State,” the court ruled, “cannot constitutionally confine . . . a non-dangerous individual who is capable of surviving safely in freedom by himself or with the help of willing and responsible family members or friends.”