• • •
One morning a woman named Nancy was admitted to my inpatient service. “Why do we look alike?” she asked me suspiciously, though she was twice my size and a different race. Before I could answer that I wasn’t sure we did, she demanded I recite the Fourth Amendment. I couldn’t. “Will you kindly get the fuck out of my room, then, and send in an American?” she asked. I left and looked it up. Ah, search and seizure. Needing a warrant. Now I know.
Nancy was in filthy clothes, and because she held a paranoid belief about the city’s having poisoned the water supply, she had not bathed or brushed her teeth in weeks. I knew from reading the report from her physical exam that she had a fungal infection beneath her breasts where they lay against her abdomen because it had been so long since she had washed herself there.
I treated Nancy for the first two days of her admission, but while she remained hospitalized, my clinical assignment switched and I began covering a different unit. When my schedule shifted back to her unit three weeks later, I saw Nancy’s name on the board and remembered our encounter. I was curious about her progress and went out on the ward to talk with her. I scanned the whole unit twice and could not find her. Alarmed, I finally approached the nurse in charge of the unit.
“I can’t find a patient. I’ve looked everywhere,” I announced, flustered.
“Which one?” asked the nurse.
“Nancy,” I replied. “Nancy, with paranoid schizophrenia.”
The nurse looked at me quizzically. “She’s right there,” she said, and gestured to a well-groomed and neatly dressed woman ten feet away from me in plain view, drinking coffee and reading the Providence Journal.
I went over to Nancy. “Excuse me,” I said. “I’m Dr. Montross, Nancy. We’ve actually met once before.”
“I’m sorry, Doctor, I don’t remember,” Nancy responded, smiling politely at me. “It’s been a bit of a rough patch for me lately. Would you like to sit down?” I did, and we proceeded to have a perfectly lovely conversation about how she was feeling (“Oh, much better, thank you”) whether she was having any problems with her medications (“They always make me a little drowsy at first, but that’s passing now”) and her plans for the future (“My husband’s been taking care of our dog, so I’m anxious to get back home to our apartment. He doesn’t spoil that dog the way I do”).
When I left Nancy, I went to the computer and read sequentially through her progress notes since I’d seen her last. My evaluation was first, documenting how she’d been out of treatment for four years prior to her admission, that she’d also accused the emergency-room physicians of violating her Fourth Amendment rights, and that she’d claimed to be homeless despite living with her husband of twenty years. She had, at the time of her admission, said that she had three children, all of whom had died of AIDS. In fact, her three grown children were alive and well and, according to the nurses, had been in to visit her several times during her hospitalization.
Subsequent physician notes revealed that Nancy had been paranoid and agitated for nearly a week after she was first admitted and that she had refused to shower or eat, convinced that the water and food were poisoned. Eventually the primary psychiatrist who was treating her took her to mental-health court. In certain circumstances, which vary from state to state, a clinician can use the same rationale that provides for hospitalizing a person against her will (danger to self or others or “grave disability”) to make a petition for court-ordered treatment. In cases such as these, which go beyond an initial involuntary hospitalization, a judge may rule that the patient must remain hospitalized, even if she does not wish to do so, and must also take the psychiatric medication she is prescribed.
The judge ruled with the psychiatrist in Nancy’s case, and Nancy remained in the hospital and was treated with antipsychotic medication. Relatively quickly her symptoms abated, and she improved.
Taking away someone’s autonomy is an uneasy balance. In Nancy’s case, with the benefit of hindsight, we now know that it was the right thing to do. As a psychiatrist, I find it immensely rewarding to see a patient delivered from fear. And this trajectory is shared by many patients, because for all the vagaries of psychiatric medications, correctly prescribed antipsychotics frequently do treat psychosis in precisely this way.
Our psychiatric diagnoses are not always as clear as we would like or as well defined as we may believe. We can’t be sure whether a person feels his life disintegrating because of Caravaggio’s puissance or because of jet lag and an underlying predisposition to mental fragility. We must weigh whether a young man has the right to fast and adopt bizarre—potentially dangerous—behaviors if he believes himself to be the devout disciple of a saint. Surely we should tread with extraordinary caution when we infringe upon our patients’ freedoms. And yet, as Nancy and many other patients have taught me, that doesn’t mean we aren’t sometimes obliged to do so.
We all long, at some point, for a profound awakening. We travel with the expectation that the places we see and the encounters we have will transform us. We go to theaters and museums and holy sites in the hope of discovering something that will have a new and permanent resonance in our lives. It’s a human hunger. We want transformative things and places and people to exist in the world, and we want to be able to tap into their power, to use them to see our lives with a new and greater clarity.
The truth is that these transformations—these awakenings—exist. Their power is experienced in galleries and on mountaintops, in libraries and in temples, at rock concerts, on psychotherapists’ couches, and in scientific laboratories. They may be subtle or life-changing, as when the young Alexander Calder, working as a fireman on a ship, reportedly woke from sleep on the deck to a sky that held both a full moon and a dazzling sunrise. The sight inspired him to become an artist.
And yet there is a line beyond which transformation can lead to upheaval. On the other side of the line is illness. Determining the moment at which this line has been crossed is difficult and inexact. As a psychiatrist, I cannot practice in hindsight. I must balance the benefits of early, preventive care with the preservation of my patients’ civil liberties and choices. Often I see patients immediately after their illnesses have thrown them deep into the wells of personal devastation. But on rare occasions I see patients just prior to when the devastation is set to begin. In those cases, how can I preserve their autonomy up to that mythical line and then jump in to treat them precisely in time to prevent them from wreaking total havoc on their lives?
As an example, I recently treated Monica, an undergraduate honors student who had chosen to film a documentary on homelessness for her senior thesis. She began by forging a connection with a clergy member who helped run a local women’s shelter. With the help of that mentor, Monica arranged interviews with shelter residents. However, as the stresses of senior year increased, she began to feel increasingly behind. In order to stay up late to study and finish work for her other courses, Monica began taking pills from a bottle of prescribed amphetamines her roommate had for ADHD. She began sleeping less and studying more. She continued to take the pills to keep up. Soon she was even more deeply impassioned about her documentary project and felt it had the capacity to ignite real social change. Her professors, her friends, even her parents were impressed by her newfound energy and her urgent conviction to do good. Before long she found she did not need the pills to stay awake. She stayed up for days at a time and hardly needed to eat. Determined to get to the “real” story of the experience of homelessness, she began working without her mentor and accompanied women, and eventually men, to spend nights with them on the street. When she began not returning home at night, her college roommates became concerned and called Monica’s parents, who flew in from Texas. Her parents discovered that during the previous two weeks Monica had covered her body with tattoos and had had sex with multiple strangers, all of which she viewed, at the time, as a means of connecting with the people
whose plight she was trying to shed light upon. They immediately brought her to the psychiatric hospital. It became clear, as my colleagues and I evaluated and treated Monica, that her fiery enthusiasm for her project had been the harbinger of a manic episode, brought about—or unmasked—by her use of stimulants. Her dedication to her cause had initially seemed so inspiring, like an awakening. Sadly, the awakening turned out to be a part of her illness, and it fueled her self-destruction.
When I met with Monica’s distraught parents, her father asked in desperation, over and over, “Should we have known? When she called us so excited, should we have . . . ? How did we let this . . . ? When should we have known?” If they had known, I reassured them, they would have intervened. But his desperate question was the very one I sometimes ask myself: At what point can we know that ecstasy, or singular purpose, or religious fervor has become pathological, if we don’t wish to wait until obvious and irreversible damage has been done? Why subject someone to the risks and potential adverse effects of medicine if her precise diagnosis has not yet been determined? The answer is that this anticipatory, proactive treatment is a fundamental and accepted component of every field of medicine.
When a woman feels a lump in her breast, she does not know what it is. It could be a benign, monthly, cyclical swelling, or it could be a malignant tumor that has already widely metastasized, or anything in between. To zero in on a diagnosis, her doctor may first order imaging—mammography or ultrasound, for instance—to attempt to determine what the lump is. If enough ambiguity remains after imaging, more invasive procedures are conducted: needle biopsies, lumpectomies. If those procedures reveal cancerous growth, still further procedures, such as mastectomies and lymph-node dissections, are routinely conducted to determine whether the cancer has spread. Mastectomies are often done on the basis of a cancerous lump that has been removed, regardless of the fact that there are no signs of cancer in the remainder of the breast. Breasts are even removed prophylactically for some healthy, cancer-free women whose genetics put them at high risk of eventually developing the disease. Women whose cancer has been treated, who have had mastectomies, who have undergone chemotherapy and radiation, who have no detectable cancer in their bodies, may for years still be prescribed medications whose risks and significant side effects are tolerated and endured because the medications have been shown to reduce the odds of breast cancer’s recurrence.
In medicine we constantly choose between two evils. We eye the balance, and weigh the risks, and make judgment calls, and predict as best we can. Whether our data include tumor markers and pathology results or a collection of mood symptoms and behaviors that indicate a dramatic change, we are trained to be vigilant but not hasty, to be proactive but not rash. Physicians prescribe medicines in order to ward off cancer recurrences and heart attacks and strokes and diabetes without knowing for sure whether these conditions would ever befall our individual patients if we left them untreated.
Similarly, I do not wish to medicate people who are simply joyous, or loving, or energetic, or passionate. Still, I cannot ignore that the stakes are high if I misread mania for ecstasy or psychosis for divine connection. So I trust in my study of symptoms and the diseases they portend. I question my intuition rigorously and routinely, but I rely upon it nonetheless.
• • •
For our tenth wedding anniversary, Deborah and I leave our children with a beloved baby-sitter and return to the Vermont inn where we were married. The four-hour drive from our home, which might have been onerous before we had children, is now a blissful chance to catch up and gossip and pontificate. As I look out the window at hills and hills of trees sliding past us, their leaves beginning to break into the colors of flame, I find that I’m thinking about a question the psychiatrist and philosopher M. O’C. Drury posed about Joan of Arc. “Supposing Robert de Baudricourt had been able to give Joan a stiff dose of phenothiazine instead of the panoply of a knight at arms,” Drury asked, imagining that today the saint’s holy visions might be treated with an antipsychotic, “would she have returned in peace to the sheep herding at Domremy?”
“What about Joan of Arc?” I ask Deborah, sharing Drury’s question with her as she drives. “I mean, if I saw someone today with her exact story—message from God, mission to overthrow the government, the whole deal—I don’t think there is any way I would come to any conclusion other than that she was psychiatrically ill. In fact,” I add, “I think the same can be said for a whole number of saints and martyrs who saw visions, or flagellated themselves, or fasted for prolonged periods of time. If I saw that today . . .” I trail off.
“But if you saw someone with those symptoms today,” Deborah says, “and they seemed to you to be at risk, or suffering, are you saying you think you’d be wrong to treat them?”
“No,” I say. “I think I’d be right to treat them. But what does that mean? Does that mean that psychiatry leaves no room for divinity? That we’d medicate a person out of what could otherwise be a transformative and saintly life? That we’d subjugate—or, worse, block—some message from God?”
“Seriously?” Deborah asks.
“What?” I say.
“Seriously? You’re worried that you are somehow blocking God’s communication to the world? Now who’s paranoid, or grandiose, or whatever you call it?” It takes me a minute to see that she is not just teasing me, that she is also—as always—very wise. She is pointing out my overly narrow assumptions about the possibilities of divine experience. “If there is a God—and you know I’m not sure about that,” she continues, “but if there is, don’t you think that how God reaches us today would necessarily look different than it did in the fifteenth century? And that God would find a way to communicate his message that wasn’t thwarted by your little pills?”
I start to grin. “You mean Big Pharma can’t kill God?”
“Yes,” she says, grinning with me. “That’s exactly what I mean.”
• • •
I still wonder what has become of Colin. I think about my fear of him that first night in the ER as he stared at me and then my imagined diagnoses for him from the photo only, both of which pegged him as angry or dangerous. Knowing what I do now about his expansive happiness and joy, I wonder if something about that much openness—that willingness to really look with love at each of us—was somehow, on some deep level, actually unsettling.
I know that my fear is that today Colin is lost somewhere with full-blown psychosis, that his happy delusions have turned to horror, or, worse, that he resumed a spiritual fast that his body eventually could not withstand. Still, I understand the urge to hope that there are people like Colin whose symptoms do not necessarily indicate a debilitating illness but rather a prophetic gift or a deep connectedness to the world.
The romantic interpretation of mental illness gets it wrong. As difficult as it is for me to medicate someone who is doing no harm, who speaks of love and connection and ideas to which we should all aspire, I know, as a physician, that Colin is ill. That too much elation is a chimera. But that doesn’t mean that those of us who treat patients in the grip of madness do not hear and receive some piece of the messages they give us, even if those messages are rooted in psychosis.
I have stood before Caravaggio’s Taking of the Christ and felt some piece of myself disintegrating. I have believed something so deeply that I would like to wrap myself in bedsheets and proclaim it from the village square.
Every diagnosis is an act of faith. I trust my own clinical intuition and acumen. That does not mean I do not harbor some uncertainty about whether my judgments are, in the end, the right ones. I am certain, however, that in my work I am not trying to diminish my patients’ capacity for fervent belief, or creativity, or even eccentricity. Sometimes there is beauty or inspiration in the extraordinary experiences of my patients’ lives. More often there is agony. Either way, by the time they come to me, their beliefs or behaviors have begun to threaten t
heir abilities to survive in the world, flawed place that it is.
“This hospital, like every other,” Annie Dillard writes, “is a hole in the universe through which holiness issues in blasts. It blows both ways, in and out of time.” She is writing about a medical hospital, about births and deaths, the comings and goings of life, the beginnings and ends. Yet she specifies—a hospital like every other. Like my own. I believe that healing is a kind of holiness. But like any good religion, it leaves me with a fair number of huge and unanswerable questions. The wind blows in. The wind blows out. Above my computer, pinned to a bulletin board next to artwork my children have made for me, a photo of Amma the Hugging Saint beams down at me. Her face is full of abundant and ubiquitous love.
(CHAPTER FOUR)
I’ve Hidden All the Knives
I will not let them live for strangers to ill-use,
To die by other hands more merciless than mine.
No; I who gave them life will give them death.
Oh, now no cowardice, no thought how young they are,
How dear they are, how when they first were born—
Not that—I will forget they are my sons
One moment, one short moment—then forever sorrow.
—Euripides, Medea
I’ve hidden all the knives,” Anna said quietly. She and I had just sat down together in a small interview room on the inpatient psychiatric unit, where Anna had been admitted the night before. I hadn’t even had the chance to ask my standard opening question about how it was that she had come to be hospitalized. She looked into her lap as she spoke, and she looked miserable. “My son is fifteen months old,” she began. “And lately we’ll be in the living room and he’ll be watching cartoons and I’ll see myself . . .” Her voice grew fainter, then trailed off. I urged her to go on.
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