Slyvester

Sylvester

Sylvester had a delicate build and was barely 5 feet tall.  He spoke rapidly with a high pitched, whisper-like voice.  His words were frequently interrupted or accented by sighs and the pursing and smacking of his lips. His mannerisms matched the fictional stereotype of an elderly lady. 

Now 60 years old, single and always celibate, he had spent his entire life with his parents.  His father had died 20 years previously. He had never been close to him and following his death his bond with his mother had grown even stronger.  They read the bible together and attended services at the Lutheran Church nearby.  He added to the income she received from her husband’s pension by giving piano lessons in their home.   He cared for her in her last years when she had become so feeble that she needed assistance with things like dressing and bathing

When mother died Sylvester had found himself without relatives or friends who could in any way substitute for the intimacy he had shared with her.  Convinced that they both had led virtuous lives he looked forward to and wished for the time when he could die and blissfully join her in Heaven.  Rather than a transient stage in the grieving process commonly experienced by many, his wish became stronger and more encompassing with each passing day.  In fact it had progressed to the point that the contemplation and preparation for how and how soon he would die had become his only purpose for and satisfaction in living.

He spent endless hours arranging for his funeral, indicating the scriptures to be read, hymns to be sung and had even written the sermon for his pastor to read.  The latter was rejected with the comment that the way he lived would determine what would be said about him at the time of his passing.   He had briefly contemplated taking a short cut to his desired end. His pastor had then made it clear that anything he might do to hasten his death would certainly result not only in a sermon he might not have wanted but, more importantly, in a permanent separation rather than reunion with his loved one.

This left Sylvester with the hope that he would soon contract a terminal illness. Each new ache or pain he would experience would be encouraging in that respect. However, while wishing to die soon he did not want to experience any of the pain and suffering that might precede it and would immediately call his family physician to request medication to alleviate his symptoms.  He had another problem that interfered with his planning. He had a germ phobia.  Because of this he was afraid of hospitals where he might come in contact with more of them that could make him sick.  To protect himself from germs when he came to my office or the offices of his other doctors he would carry a bright yellow child sized Sunday School chair and would sit on it in the waiting room as well as when he came into the office.  To avoid the risk of exposure to germs in a hospital he arranged for social services to provide him with a hospital bed in his home where he could be cared for in his last days.

Sylvester continued to visit me periodically over the course of many years in order to satisfy the requirement that he see a psychiatrist in order for his SSI payments to be continued. I think he also enjoyed the opportunity to fill me in on his progress in terms of his attempts to meet his goal in the best way possible. I learned very soon that the worst thing I could do was to say he was looking relatively healthy. He’d smile, however, when I’d tell him that it looked like he might be going downhill just a little bit.  He once explained to me how delighted he had been after he had sought an opinion from a neurologist who had informed him that he was of an age where he might certainly sustain a fatal “stroke” that would be quick and painless.

Was Sylvester eccentric?  Yes.  Was he mentally ill?  Maybe.   But I remain comfortable with the decision I had made after our first meetings to avoid attempts at treatments that he was not seeking, treatments that were doomed to fail, treatments that might detract from the special meaning he had found in his life, a meaning I was allowed to share.

  

Susan

SUSAN

During my last year of residency I was asked to see Susan for a consultation on the neurosurgical ward.  She had been admitted there with the suspicion that she might have a brain tumor.  Extensive testing, however, had failed to reveal any treatable pathology.  Following a myelogram she had developed a headache that had been prolonged and incapacitating in its severity.  When I saw her and also talked with the staff providing her care it appeared that a situation had developed in which they viewed her symptoms to be more faked or at least more psychogenic than real. She, on the other hand, was experiencing her symptoms as very real and blamed staff for their inability to provide her with a proper diagnosis and treatment that would give her relief.  As I saw it, it was a situation in which both factions blamed the other for her lack of progress.  I speculated that things had developed to the point that she could not give up her symptom without the loss of self- esteem that might accompany a spontaneous recovery without further physical treatments.  It also seemed clear that further testing would be contraindicated and would only make things worse.

Susan was bright, young, attractive and suggestible.  She was not psychologically sophisticated and I did not think she would respond to interpretations related to what I had observed.  I decided that a better approach might be to utilize hypnosis as a way to give her permission to get well. 

The first problem was that I had never hypnotized anyone.  An additional problem was that most of the psychiatrists and psychologists who were my mentors did not view hypnosis as a legitimate type of treatment

I made an appointment for Susan to see me the following day in my office.  In the interim I read the most authoritative volume on hypnosis I could find in the library.  Upon her arrival I explained that I had concluded that her headaches had initially been caused by her myelogram but were now being perpetuated by tension.  I further thought that if we could replace this tension with relaxation, a vicious cycle (pain creating tension and tension prolonging pain) could be interrupted and this was likely to result in her headaches going away for good.  I explained that hypnosis, in the way I was suggesting we use it, was a way to facilitate her ability to make this happen. I emphasized that I would not be doing something to her that would take away her pain.  I would simply be helping her to do so. I explained that she would remember everything that transpired and that if at any time she felt confused or uncomfortable she would be able to wake up and terminate the procedure. 

After she agreed to give it a try, I had her lie down on the couch in my office and began to repeat the lines I had rehearsed from the book.  Somewhat to my surprise she rapidly responded to suggestions involving things like hand levitation and eye closure.  I was momentarily distracted by the thought that my training supervisor might not approve of what I was doing when I would present Susan’s case to him later.  Putting these thoughts aside I proceeded. When she appeared to be in a hypnotic state I essentially repeated what I had told her before we had begun.  I suggested that her state of tension was being replaced by a state of relaxation and that as this was occurring she would notice that her pain was going away.  I also suggested that now that she had broken the tension cycle her pain was unlikely to return.  I suggested that she would have full recall of what had happened and upon awaking should feel free to discuss or ask questions about anything that had occurred.  When awakened and asked how she felt she said that for the first time in over a week her headache was gone.

Susan was discharged from the hospital later that day.  I asked her to make an appointment to see me for follow up two weeks hence.  Upon her return she indicated that she had remained free of headaches.  She, however, had decided that her real problem had been with her glasses and had obtained a slight change in her prescription.  I supported her conclusion and asked if there was anything else she wanted to ask or talk about before ending what would be our last meeting.  She said the only thing that she had noted was the occurrence of vivid dreams with sexual themes on the night after the hypnosis and wondered if I thought this was significant.  Rather than delve further I responded that I didn’t think dreams like these were likely to be interpreted in ways that would be helpful to her.

When I discussed the case of Susan with my supervisor I was greatly relieved. Rather than admonishing me, he complimented me for utilizing an approach much different from the slow moving, psychoanalytic, dynamic approaches taught in our program at that time that had placed very little emphasis upon treatment of specific symptoms.

Over my years in practice I utilized hypnosis on several occasions, usually with good results.  I never used it as a means to get someone to disclose information that he or she might not feel comfortable in sharing in a face to face session.  Based upon my experience with Susan, I always had a nurse, family member or female office staff present during the procedure with my women patients.  I found this technique useful in speeding the treatment of phobias.  I found that some patients were able to generate a strong analgesic response and could then be taught how to induce the hypnotic state themselves in order to bring about this effect.  Often it succeeded because it gave someone like Susan permission to get better without the loss of dignity.

Richard

Richard

Richard was a professor at a local college and was held in high esteem by his students and colleagues alike.  I had heard about his good work but had never met him when he called me at the office asking for an immediate appointment, saying his need was urgent.  I agreed to see him after my last regularly scheduled patient at 7 PM.  I had just begun my private practice and was renting an office in an old building that was entirely vacant at that time of day.  My part time secretary had gone home several hours earlier.

When he entered the room I was impressed by his aggressive stride and his large and powerful physique.  He chose a chair opposite a massive butcher-block coffee table and I sat down opposite him.  Before I could do more than introduce myself he told me that he held a black belt in the discipline of Karate.  He went on to say that he was troubled by aggressive thoughts. He then looked at the coffee table, gesturing a Karate chop as he said he was capable of splitting my table in two.  With still more excitement and volume in his voice he exclaimed, “I could do the same thing to your skull!” 

After a brief silence I looked up at him and said, “You are scaring the shit out of me.”  After another brief pause I went on to explain that I didn’t think I would be able to be the objective and caring doctor he deserved if I were to be distracted by fear for my own safety.  He immediately relaxed and related a history of intermittent episodes of depression.  He also talked about current stresses in his life that included a ménage a trois relationship which had gone from beatific to horrific.  He talked about times in his high school years when he had had a problem with his temper and how he had struggled all of his life to keep it controlled. 

A few meetings later he explained why he had approached me in the way he had upon our first meeting.  He had read a lot about Freud and psychoanalysis and thought therapy would progress faster if he started out by expressing his most primitive and uncivilized “id” thoughts and feelings.

I saw Richard on several occasions when he felt the need to do so as well as to monitor his medications over the next 20 years.  I’ll never know what aggressive thoughts and fantasies he may have entertained during those times because he never shared them or directed them toward me.  In fact, a relationship that had begun with his frightening domination of me had quickly morphed to one in which he felt very dependent upon my approval, reassurance and even my advice.

Tillie

Practice Story, Tillie

Tillie was one of my first patients when I began what was at first a part time private practice.  She was 40 years old and had been seeing psychiatrists all of her adult life.  She was dressed in vividly contrasting colors. She was not attractive but she was engaging. Her speech was rapid, loud, and accompanied by frequent smiling.  She had never been married but had had many steady lovers over the years.  Most of them had been married salesmen who would phone her and arrange for a tryst when their jobs brought them to this area. She was a regular churchgoer. She loved her pastor and the congregation where she worshiped.

Tillie appeared to have lived her life in a continuous hypomanic state.  This had not impaired her ability to function at work.  Over the years she had advanced from being a telephone operator to that of a middle executive position in the phone company.  When the company was downsized her office was closed. Rather than move to a different city she took a job as a sales woman at the local Sears Roebuck store where she was also very successful.  Her main psychiatric symptoms, which on some occasions caused her to experience distress, were auditory hallucinations and delusional thoughts. 

Her previous psychiatrist had treated her with psychotherapy.  She had enjoyed her sessions with him and had even accepted the fact that these sessions in which her intimate thoughts were expressed had not led to what she thought would be a less professional but more personal and immediately satisfying intimacy at a local motel. It was my opinion that medication would be a better way to treat her symptoms.  She agreed to take an antipsychotic drug.  

At the end of this first interview I asked her if there was something more I should know that I had not asked her about in this first meeting.  I also asked her what her expectations were in terms of how I could best help her as her doctor.  After a pause she said the only thing more she would wish for would be for me to give her a hug.  I was unprepared for this request. I didn’t want to hurt her feelings by rejecting her but it was clear to me that a hug would not be appropriate or in the long run helpful to her. Somehow I was able to muster a quick reply, one I hoped she would find acceptable.  I told her that I never hugged my patients.  The only exception might be at a time when I knew treatment was being terminated.

Tillie continued to see me until the time I retired.  Medication did not totally eliminate her referential auditory hallucinations.  For example, once upon my return from a family trip she reported that while shopping at the local grocery store a voice was broadcast over the intercom that was clearly intended for her. The voice said, “You should get a different doctor.  The one you have now goes on too many vacations.”

The last time I saw Tillie, some 30 years since our first meeting, she was stable.  She was not hallucinating and was not describing delusional thoughts. She was tolerating her medication with no symptoms or signs of toxicity.  Based upon our previous discussion she had chosen a psychiatrist to take my place now that I was retiring.  When our appointment time was finished she got up from her chair and walked slowly toward the office door.  Half way there she stopped, turned to face me, held out her arms, smiled broadly, and said, “I’ll take that hug now.”

Pearl

Pearl

Pearl was 81 years old when she was brought to see me by her husband and daughter–in- law.  They noted that she had been having problems with her memory over that past three years. Her husband of almost 60 years had been her caretaker and up until recently had felt comfortable in this role.  Recently she had been getting up during the night and at these times would become agitated. On a couple of occasions she had wandered outside the house.  

Pearl was a pleasant and engaging lady.  She had moderately severe deficits in her orientation and memory.  Considering the degree of her dementia, however, she had an amazing ability to carry on a conversation in a goal directed and sometimes appropriately humorous fashion.  She could still talk meaningfully about her childhood days spent on the farm.  It soon became evident, however, that she did not know that the man and woman who had accompanied her to the office were her husband and her daughter-in law.

After discussing possible risks and benefits I prescribed a very low dose of a major tranquilizer to take at bedtime and requested that they return for a brief follow up a week later.

Upon their return her husband and daughter-in-law indicated that Pearl was now sleeping through the night and was again quite manageable at home.  I next turned to Pearl and asked her if she remembered having seen me before.  She said, “Sure.”  Her husband and daughter-in-law, not surprisingly, looked shocked, knowing that she had continued to be unable to recognize either of them.  I then asked her where it was that she had last seen me.  She said, “We were out dancing last night.”  I apologized for asking such a silly question and asked her, “How did I do?’  She replied, “Nothing above average.”

Pearl continued to decline and several months later required around the clock care in a nursing home.  She no longer needed medication for episodes of agitation but developed an intractable stiffness of her neck that was probably caused by the tranquilizer I had prescribed for her.  Fortunately, it did not appear to cause her physical discomfort in her remaining days.  This did make me more cognizant of how thin the line can sometimes be between risks and benefits in our attempts to be helpful.

2006  

Paula

Paula

Paula had scheduled an appointment with the office secretary a couple of months previously.  She had made no mention of why she wanted to see a psychiatrist. She said a friend had recommended me.

When she entered the office I was immediately struck by her appearance.  She was tall, slender, well proportioned.  Her skin was lightly tanned.  Her eyes were engaging.  She was smartly dressed in subtle colors. When she began to speak, her voice was husky and mellow. 

I soon became aware of the fact that I found her to be sexually attractive.  This was an unusual experience for me in my practice.  I quickly reassured myself with the thought “She’s young and beautiful, dresses well, relates warmly and appropriately, who wouldn’t be attracted to her?”

After obtaining some basic information I asked her what had brought her to see me.

She said she had been requested to obtain a psychiatric evaluation before undergoing an elective surgical procedure that was to be performed by a surgeon in Colorado. She then explained that her name was Paul and not Paula and that she was seeking surgery that would change her sex from male to female.

She went on to describe how ever since she had been a small child she had felt like a girl and later a woman trapped inside a male body.  She had managed to relate to her peers in ways that did not lead to being singled out as effeminate or gay.  She had participated in sports and had performed up to the junior varsity level in high school.  She had not dated.

She had confided her feelings to her parents at an early age and they had remained supportive and accepting of who she was. Although they were not in a position to help her financially they did approve of her quest for a sex change.  She had been engaged to a man for over 3 years who also approved of the procedure and they planned to get married as soon as she recovered.

Paula was now 35 years old and had been living in San Francisco where she, for the past 10 years, had lived as a woman.  She had attended regular group therapy sessions for people considering sex changes.  She had taken hormones that were prescribed to her to decrease her masculine features. She had undergone a painful procedure to remove her facial hair. 

Nothing in this interview suggested that Paula was unstable or that her judgment was in any way impaired as she was making this life changing decision.  I informed her of my conclusion and indicated I would later that day send a report to her surgeon in Colorado in which I would strongly recommend that she receive the surgery she had requested.

Dictating the report was both easy and difficult.  It was easy in the sense that I was confident that Paul would live a more fulfilling life having his physical attributes replaced by those of a Paula.  The difficult part was keeping track of the pronouns he, she, him, her.  In spite of the fact that Paula was still a Paul physically, the person with whom I had just interacted was certainly a woman.  So, just like in the narrative above, I just stuck with the she and her. 

I never saw or heard from Paula again.

2006

Nurse's Call

Nurse’s Call

It was maybe 3 o’clock in the morning when I received a call from the psychiatric unit.  This was not an unusual event.  A patient had just been admitted via the E. R. and I had been assigned to his care.  After the nurse briefly summarized his current status she asked for orders to cover his needs until I would see him 4 hours later.  I apparently responded with a recitation of routine laboratory and PRN orders that would suffice and hung up the phone.  My wife immediately shook me until I was fully awake and asked me if I was sure I had been alert enough to give the nurse orders for this newly arrived patient.  I said I thought so and asked why she might be concerned.  She responded, “Because before you hung up you said good night, I love you.”

Fortunately, the nurse who had called was the oldest and most competent on our staff.  She no doubt knew I was not awake enough to be able to make good decisions and had she thought cogent thinking was required on my part would most certainly have called again.

2006