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

Mrs B

Mrs. B

Mrs. B had moved to our area with her husband after having spent the previous 58 years in Manhattan.  She had made regular visits to her analyst during most of her adult life there and had decided she should find another psychiatrist to talk to. Upon discovering there were no psychoanalysts within 100 miles she decided to try me out. 

Mrs. B was a very sophisticated appearing and sounding lady.  She had attended a prestigious women’s college in the East.  Her husband had been a successful businessman and had pretty much catered to her every material wish.  They had not had children and it was not clear whether this had been by chance or choice. 

In our initial interview she recounted facts rather than concerns about her family, education, marriage and herself. She did not have a chief complaint and did not describe the course of any particular mental disorder.  It was my impression that what she was now seeking was the continuation of a ritual that she had found in some way or ways useful in the past.

Apparently I had met her expectations in my first trial session because she requested a follow up appointment.  On her return she voiced both a complaint and a request.  She noted that her husband who was 20 years her senior was impotent.  She went on to say that her analyst had told her that this represented passive-aggressive behavior on his part aimed at denying her the pleasure she deserved.  According to her report, her analyst had seen him in order to confront him about this just prior to their move.  Unfortunately, his impotence had continued in spite of the reprimand and she requested that I give him a boost by asking him to come in to see me for a similar session in which I would give him the same message. 

I said I did not think it would be appropriate for me to do so.  I explained that although some cases of impotence resulted from psychological problems it had been my experience that most men in his age group experienced this difficulty because of physical conditions that decreased the blood supply to the penis. (I thought to myself that if she related to her husband in the demanding and hostile manner she did with me it would not take a stretch of imagination to imagine why he was unable to get an erection in her presence on a psychological basis as well). I offered to see them together to discuss not only their feelings but how their problem might be better assessed and treated.  She was not happy with my response and said she thought it would probably be a good idea to find another psychiatrist who might be more supportive and responsive to her needs.

A couple of months later she called back to say she had decided against seeing a different doctor and would like to continue seeing me.  I must admit that her decision was not the one I would by now have hoped for. 

On the occasions that she saw me during the ensuing year she often made the same complaint and request regarding her husband that I responded to in the same way.  She continued to fire and rehire me. She spent most of the time during our sessions pointing out what she had observed in terms of my faults when compared to her analyst in NYC.  When she finally made a permanent decision to discontinue her visits she did so with the comment,  “If you think you’re such hot stuff, what are you doing in Oshkosh?”

2006

  

Mort

Mort

It was my second day on duty at Valley Forge Army Hospital. I had been assigned there after completing my internship to participate in “On Job Training” in psychiatry. Training thus far had only consisted of being issued a set of keys to get me in and out of the ward that housed the psychotic patients who were now under my care.  It was mid morning when I got a call from the staff sergeant who served under the commanding officer.  I was told that there was a problem with one of my patients at the gymnasium and that I should report there immediately.

When I arrived I found that one of my patients, Mort, had somehow climbed up to the exposed ceiling supports high above and was threatening to jump. The place was full of officers and enlisted men that had already responded to the crisis.  A movie set could not have better depicted the urgency and anxiety emanating from those in attendance.  The officers were mostly conversing while the enlisted men scurried about. Several of them were trying to position a safety net to catch him should he go through with his threat. In addition. a long ladder had been extended up to him.  I can’t recall whether it was my idea or that of one of my senior officer’s and whether it was a matter of volunteering or being commanded to do so.  At any rate I soon found myself somehow managing my moderate fear of heights as I slowly climbed upward. When I got within about 10 or 15 feet I began to talk to him, not having the slightest idea of what a psychiatrist would or should say in such a situation.  I said to him the following: “ It looks like you’re having a bad day and I guess you might be feeling pretty upset about something.”  I went on to say that I, at least, found this a pretty uncomfortable place to talk and suggested he climb down the ladder with me so we could return to my office where we could better continue our conversation.  Much to my amazement he agreed and followed me down to safety.

Once back in the office it became obvious that Ralph had been responding to command hallucinations that had been telling him that he should kill himself by jumping off the rafters of the gym.  Lucky for him and lucky for me, the voice had also told him that he should follow my advice.

I suspect that some of the men who had witnessed what happened in the gym that day were impressed by what appeared to be the persuasive skills that only a trained psychiatrist would be able to employ. I didn’t interrupt my moment of fame by explaining otherwise.

2006

  

Jenny

Jenny

“I’ve been stalking you for 3 months. I know everywhere you go and when you go there.  I have spent all this time deciding when and where to kill you.  I have a gun.”

She talks in a monotone and her face is expressionless as she sits in the chair opposite me, her jacket on her lap.  I immediately question to myself whether the gun is hidden beneath, having entered the office behind her, my vision obstructed by the back of her chair.  I have an impulse to grab her knowing that I am bigger and stronger than she.  I think better of it.  With a false calm façade I inquire why she is so angry with me.  It turns out that she thinks and feels that I had abandoned her. Speculating that attempts to convince her otherwise in this moment would likely prove futile I appeal to her sense of the consequences like jail or prison that would follow this act.  She replies that her plan is to kill me and then kill herself.  After further conversation that remains a blank in my memory I tell her that she must admit herself to the hospital.  I also inform her that I will not be her doctor while she is there.  I tell her that I will be calling the hospital to alert the staff regarding her admission.  The hospital being a 10 minute walk away from my office, I tell her that I will call the police if she does not arrive there within 15 minutes after she leaves.

Jenny first became my patient when she no longer had insurance or private funds to pay her private psychiatrist.  She had been admitted to our psychiatric unit on a police detention after making suicidal threats following a breakup with her girlfriend and her case was assigned to me.  I had, seen in retrospect, made the mistake of agreeing to continue to care for her gratis after her discharge. She had been raised by a sexually and physically abusive father and I had apparently become the good father she had always desired and deserved. When she on a later occasion was again detained in the hospital because of suicidal threats she was penniless and without a place to live.  The county mental health team arranged for her to reside in a group home with the stipulation that she would need to see the psychiatrist on their treatment team rather than continue her contacts with me. This, I later found out, was what she had interpreted as my rejection and abandonment of her.

Over the years I had seen many patients who had the potential to harm themselves or others and on some occasions had had to call family or police to intervene for their safety or the safety of others. I was also aware that the practice of psychiatry carried with it a greater than average risk of being harmed. I had received indirect threats on some occasions.  For example over a period of about 3 months I had received daily anonymous notes sent to the hospital, office and my home saying things like, “Time to meet your Maker” and “You won’t be poisoning more people with your drugs.”  I never found out who had sent them.  There were times when I would be concerned about consequences when in the process of supporting a patient this could be misinterpreted.  For example, the wife of a paranoid, abusive husband once told me that she had confronted him by quoting me as saying, “Harry is a SOB.”  This is what she had told me and not what I had told her. I did consider the possibility that he might seek me out sometime and that the meeting would have the potential for turning ugly.

This was the first time, however, that my own safety was clearly and imminently at stake and the first time that my response was visceral.   I had always felt capable of experiencing empathy and would, for example, find myself beginning to tear up when listening to a depressed patient. This would clue me in to the fact that I should inquire about possible suicidal thoughts or intent.  I could feel for the anguish and fear experienced by the spouse of a threatening, paranoid partner.  But the intensity of these feelings for others was infinitesimal compared to that I now experienced when it was my own life being threatened along with the thought that over the past 3 months, that I could have been killed at any time, never suspecting that I had been in danger.

My symptoms were not unlike that of a Post Traumatic Stress Disorder.  I was frequently awakened with nightmares that had the common themes of being chased and attacked.  I often relived what had transpired during the ensuing days and weeks and worried that she would buy another gun after discharge from the hospital (the one she had at her apartment had been confiscated but this was the third one she had purchased from local gun shows) and pursue me once again. I sometimes questioned the competency of the therapist at the county clinic who had been assigned to her care and feared that she might not understand the gravity of my situation.   When leaving the office in the evening I might see something or someone as harmless as a little old lady in the distant periphery of my vision and that would be sufficient to startle me. I found myself closing the curtains on windows where I could be seen sitting in the house in the evening. 

Over the course of a few months my fears and preoccupations abated.  Jenny remained under the care of her therapist and psychiatrist at the county clinic and I heard nothing more about her until a few years later when she shot herself through her left eye.  I do not know the details surrounding this event.  I was told that she had recovered completely except for the loss of that eye. 

I didn’t see her again until after I had retired years later.  I was at a local restaurant attending the cocktail hour prior to our county medical society meeting.  She approached me wearing a black patch over her missing eye, greeted me with a smile and hugged me.  She then told me that she and her partner had bought a new home and that they were enjoying their life together, no longer having the disagreements that had plagued them in the past.  I awkwardly indicated I was glad her life had taken a turn for the better and we parted.

There was not even a hint of dangerousness in Jenny’s demeanor in that last meeting. I do wonder now what may have caused or contributed to her changes in attitude and behavior. Did this occur as result of her therapy?  Was this a result of what may have been a self inflicted frontal lobotomy by the bullet to her head?  Did it simply evolve as a natural event over the passage of time?  I’ll probably never know.

2006  

James and Marie

Alzheimer’s

James and Marie

I arrived on the psychiatric unit first thing in the morning and found I had two new consults to see.  They were an elderly married couple that had been brought to the hospital by Social Services with a court order to be evaluated regarding their mental competency and their possible need for protective placement. The history provided by the social worker described James and Marie as having lived all of their lives in our city.

They had known each other since grade school and had begun dating in high school. They had been married for 58 years.  They had been unable to have children of their own but had over the years raised several foster children. They had been admired by all who knew them.

Unfortunately they had not been faring well in recent months.  Neighbors became concerned about their safety and requested that Social Services intervene.  When the social worker arrived she found the house to be in a mess.  Spoiled food and garbage were everywhere.  Both of them were unkempt and inappropriately dressed.  They appeared to be confused but seemed happy that they had company and didn’t resist coming to the hospital.

When I approached them they were sitting very close to each other on a small bench, holding hands. Due to the efforts of the nursing staff they were now bathed and neatly attired.   I first turned to Marie and after introducing myself, asked her if she could tell me who the nice man sitting next to her was.  She smiled and said she could not.  I then turned to James and asked him if he could tell me the name of the nice lady he was sitting next to.  He said he didn’t know.  I then said that I noticed that he was sitting very close to her and asked him if he thought he might possibly be married to her.  He grinned at me and said, “No, but I’m working on it,” as he snuggled even closer.

2007 

   

Hubert

Hubert

I first saw Hubert when he came to the hospital to provide information regarding his wife.  She had been admitted to the psychiatric unit on a detention order after being arrested by the police.  She had been driving her car down main street in the late evening at 60 miles per hour.  When they apprehended her she was naked. She was in a manic state and responded to treatment with a combination of lithium and an antipsychotic medication.  However, she was not very compliant with her medications and her illness was severe.  This resulted in multiple hospitalizations over the next few years.  Hubert, in spite of many interactions with the staff including myself could never quite understand how these behaviors could be a product of mental illness rather than volitional choices on her part.  This ultimately led to his decision to divorce her. Soon thereafter she was placed in a group home where psychiatric treatment was provided by the local county mental health clinic.

About 10 years later, now remarried, Hubert was referred to me by his family physician for treatment of an Obsessive Compulsive Disorder.  His repetitive behaviors were seriously interfering with his work as well as his family and social life.  His speech was concrete and circumstantial.  His main and seemingly only interest was the church he had joined after his divorce.  It was there that he had met his second wife and had been born again.  Almost all of his family and social activities took place there. He spent his break times at work quoting the bible. trying to convince his fellow employees to find the truth so they could be saved as he surely had been.

His compulsive rituals responded well to treatment. During his return visits that were scheduled for support and monitoring of his medication he talked about his religious thoughts and endeavors.  On the third appointment he asked me what religion I belonged to and practiced. I would usually be very open with patients who would ask this.  I would explain that I was not religious and that if that were important to them I knew a psychiatrist in the area who was not only religious but utilized biblical teachings as part of his therapy.  I would then offer to make a referral to this doctor if they so desired. 

But the situation with Hubert was unique as I viewed it.  I did not think his needs would be better met by a doctor who stressed the bible since he was already overly preoccupied with it.  So I responded that I did not think it would be appropriate for me to tell him my religious preference. Not satisfied with my refusal to answer his question it became his goal to find out which place of worship I was attending. It apparently never occurred to him that I might not belong to a church since he perceived me as a good person and he viewed the one as incompatible with the other.  He expressed his frustration with being unable to find the answer. On Sunday mornings he would park his car across the street from my house with the thought that once he would see me leave he could follow me to my destination and his question would be answered.  The problem with his plan was that his church was a twenty minute drive from where I lived and he could never allow himself to be late for his service. He’d wait until the last possible moment until he would feel ineluctably compelled to drive away. He repeated his vigil Sunday after Sunday to no avail and finally concluded that the church I attended must have been closer to my house than was his. 

Hubert remained under my care for many years. My secret remained intact and I’d like to think this contributed at least in part to the success of his treatment.

2006  

Frieda

Frieda

Frieda, a single, mildly to moderately retarded forty five year old lady entered my office sobbing. Her sobs waxed and waned but never went away during our hour together.  She was leaning on the shoulder of her older sister, Edith, who was gently leaning back, trying with each lock step to console her with soft supportive words.  It was the sister who had arranged for an early emergency appointment explaining that she for many years she had acted as the unofficial guardian and protector for her sister and that she needed help now. 

With support and occasional prompts from her loving sister, Frieda did her best to describe the problem that had led to her coming to see me.  She had been arrested for shoplifting at a local department store the day previously.  She had acted impulsively and was now overwhelmed with guilt. She had never done anything like this before and was sure she would never do something like this again. Naively and concretely her story unfolded. She had purchased a blouse that had been offered at a sale price at the store a few days previously. After wearing it only once she washed it. It faded and shrank to the point that she could not get into it.  She returned it to the store and was told that because it was purchased on sale no refund was available.  She was angry and it was while in the midst of her anger that she spotted a piece of cheap jewelry. It was at this moment that she decided that it would only be fair for her to take it and make things even.  Her theft was observed and the arrest soon followed.

But there was more.  Turned out that the two supportive influences in Frieda’s life were her sister and her church.  She belonged to a fundamentalist sect and had not missed a service, whether on a Sunday or during the week. in the last 25 years.  Much of her self-esteem was derived from the things she had done for the congregation to which they had responded by honoring her as one of their special members.  Unfortunately, this same congregation was not long on tolerance when one of their members engaged in behaviors outside the morals of the group. And now the core reason for her coming to see me came to light.  Her arrest was to be published in the paper and it was likely that one or more of her fellow worshipers would read it. Once her transgression was known it was almost certain that she would be ostracized by these most important people in her life.

The more I listened the more impressed I became with the genuineness of Frieda’s account. I could see how she would react in the child like way she had.  My sympathy for her was probably even further enhanced by what I viewed as the intolerance practiced by some fundamentalist religions.

I quickly reviewed the biopsychosocial approach to diagnosis we like to propagate in the practice of psychiatry.  The idea is to treat that which is most changeable.  Biologically she was retarded.  Could I change that?  Psychologically she was unsophisticated. Her problem was clearly social and it was here that an adjustment could make things better.

I called the newspaper and talked to the editor. I gave him an abbreviated version of what had happened with Frieda and told him that it was my best medical opinion that publishing Frieda’s name and what she had been arrested for would seriously impact her life in a devastatingly negative way.  I colored this with a description of how guilty she already felt and what I saw as the fact that she could no longer have a reasonably meaningful life without the support of the group that would almost certainly shun her should her name be published.  After initially saying this was not possible, he agreed to let her remain anonymous. 

She and her sister left the office feeling much better.  I felt good about myself, having saved a kind and needy soul from more condemnation than she deserved and in so doing having allowed her to live the rest of her years with less feelings of guilt and the continued support of her church.

Three months later the same newspaper published an account of two sisters who allegedly had been involved in a series of shoplifting episodes in local stores.  One had acted as the lookout person and the other had done the actual stealing.  On this occasion the sister, Frieda, who was the lookout, had decided to get a piece of the action.  She had done so clumsily and they were caught. This is most likely what had happened on the occasion prior to the time I had seen her in the office and. as it turns out, got her and her sister off the hook. 

2007

Evelyn

Practice Stories

Evelyn

Evelyn was married and had 3 loving daughters and a loving husband.  She suffered from a chronic depressive illness that had required multiple hospitalizations prompted by suicidal thoughts and intent.  These episodes occurred in spite of the fact that she always kept her office appointments and was compliant with all treatments prescribed.  This admission to the hospital was again prompted by depression but it was occurring within a different context.  She had for quite some time been receiving renal dialysis for kidney failure and had decided to discontinue it, knowing that this would result in her death.

She couldn’t sleep at night, her energy was low and she had little appetite. Her speech was slow and impoverished. Her affect and mood were severely depressed. She did not say that her decision regarding discontinuation of dialysis was a way to kill herself..    However, I was concerned about her capacity to make a rational decision while in such

a severely depressed state.  I discussed my concern with her and her family and proposed that she should not make this decision until her depressive symptoms had improved. When she balked at this idea I said that I would then feel compelled to refer her to the court with the question of whether she was competent to make that decision at that time.

I explained to her that I would in no way attempt to influence her decision once her mood had improved.

With this threat and the encouragement of her family she agreed to continue her dialysis and accept further treatment of her depression. A day or two later I was making hospital rounds accompanied by a psychiatric resident. I, among other things, was trying to teach her how to interview patients in a way that would allow them to express their feelings.

When I approached Evelyn she was lying in her bed, staring blankly at the ceiling.  A direct question as to how she was feeling was met by silence.  Other questions about her care, family visits, etc. were met with the same mute response.  I then indicated that I suspected that she might have lots of thoughts and feelings she might wish to share at a later time. In addition I indicated that I would make sure extra time would be available if she should feel more like talking on the next day.  Having said this, I, with the resident tagging along, walked away.  Just as we reached the doorway of her room she shouted, loud enough to be heard throughout the entire unit, “Goodbye Asshole!”

In the ensuing couple of weeks her depression lifted and we were on the good terms we had shared in the past.  At that time she once again considered whether she should or should not continue with her dialysis.  She decided to discontinue it and her family and I were comfortable with the fact that she was now competent to make a decision only she could make.

JohnB McAndrew MD

2006

Ella

Ella

Ella was in her mid thirties when she first came to see me and I continued to see her on a regular basis until her death 20 years later when she apparently choked while eating a piece of chicken. It still worries me that her medication may have impaired her ability to swallow and contributed to her demise. She had been previously diagnosed with schizophrenia but during the years I treated her she did not report recurrence of hallucinations or delusions.  She managed to live independently on her SSI payments.

Ella dressed and related like a troubled teenager. Like many in that age group, her aspirations had little to do with a realistic appraisal of her potentials. Her ambition in life was to become a famous violinist.  The first hurdle in her climb to fame would be for her to be accepted to play in the string section of our local symphony orchestra. It never happened in spite of the fact that she attended tryouts every year only to be rejected again and again. This, however, did not in any way diminish the fervor with which she continued to pursue her goal or her confidence in being able to accomplish it.

As I saw it I could best help her (in addition to monitoring her medication) by offering my unwavering support. She had no friends or family that were able to do so.   It turned out that the way this could be best accomplished was for me to become her audience.  She would bring her violin to our sessions along with a cassette player.  She had obtained a recording of a Mozart Violin Concerto that omitted the violin part and this allowed her to play with the back up of the symphony orchestra. She lacked pitch, rhythm and technique and after a few bars of the cassette recording, there was no longer any relationship between what she was playing and her accompaniment.  It was the kind of performance that had led her to be dismissed by the many teachers she had consulted over the years; however, my role was to listen and dismissal from my care was not an option I would have entertained. When our time was up she would put her violin back in its case.  I would encourage her to keep practicing, and in response she would smile, obviously pleased with her progress. 

Unfortunately, I do have an awareness of rhythm and pitch and an appreciation for the music of Mozart.  These early times with Ella stretched my capacity to provide the support she needed in the best way I knew how to give it.  As the years passed, however, I grew fond of her and her eccentricities to the point that I began to look forward to her concerts.

2006

Charlene

Charlene

The first time I met Charlene was when she was brought to the psychiatric unit by police on a detention order with a request to evaluate her to see if there was probable cause for commitment to psychiatric treatment.  She related an interesting story.  She had been driving her car when God told her that she should take her hands off the steering wheel and leave the driving to Him.  This was obviously a dangerous variation of the Greyhound bus “leave the driving to us” theme.  Not surprisingly, her car went off the road and didn’t stop until she crashed into the local WallMart store. 

She was grossly manic.  Her speech was loud, rapid, uninterruptable and mixed with singing and shouting. She would rapidly switch from topic to topic.  She was inappropriately seductive.  She was almost constantly on the move and would alternate skipping with pacing up and down the hallways.  She was grandiose. .  Her mood was euphoric. She had no insight regarding the potential danger to herself and others related to her recent behaviors

Charlene responded well to a combination of Lithium along with frequent intramuscular doses of a major tranquilizer and within 2 weeks she was no longer showing signs of mania.  She then presented herself as a bright, emotionally stable lady who had functioned well as a mother as well as in her job as an executive secretary. Her recall of her psychotic episode was scanty but she was able to accept the idea that she should continue her Lithium with the hope of preventing this from happening in the future.  She was discharged and agreed to continue seeing me on an outpatient basis to monitor her medication.

Charlene did well for the next couple of years except for some minor side effects from her medication that were easily managed.  Then she decided that she no longer needed treatment, stopped her visits and discontinued her Lithium.  About 3 weeks later, the police brought her back to the psychiatric unit on another detention order.  She was manic and had once again accepted the advice to take her hands off the steering wheel and leave the driving to God.  This time she had smashed into a parked car. 

Charlene responded well to the same treatment given during her first episode and, in fact, did so, so rapidly, that 3 days later when she was scheduled for a probable cause hearing she was no longer showing signs of mania.  She had, however, confided to the nursing staff that she did not think she really needed to take medication and intended to immediately discontinue it as soon as she would be discharged.

At the time of the hearing I was asked whether she met the criteria for commitment for further treatment based upon being at that time imminently dangerous to herself or others.  I said that in her current state she was not, but based upon her stated plan to discontinue her medication and her prior history, was likely to soon become so.   I was asked whether I could state with medical certainty that this would occur.  I asked the judge and the attorney appointed to represent her if they could furnish me with a percent of certainty that they would accept as being reasonable and was told my place in the hearing was to answer questions, not to ask them.  So I went on to say that based upon my medical training and experience I thought there was more than a 50% chance that she would stop her medication, that her mania would recur soon and that this would be accompanied by the emergence of behavior dangerous to herself and others.  The decision was made that she did not meet the criteria for imminent danger caused by mental illness and that she could not be detained against her will.

Charlene was immediately discharged and a voluntary follow up appointment was scheduled at my office the following week.  She did not keep her appointment and her family reported that she had vanished from the area.  A few days later they reported that she had decided to drive her car to Canada.  They had been informed that while on a Canadian highway she had followed the advice of God to let Him do the driving.  She had ended up in a ditch and had been taken to a psychiatric facility nearby where she was being treated for her mania.  Further follow ups with the family revealed that she had been hospitalized there for a little over 3 months before her physician and the court decided it was safe for her to get back on the road.

I saw Charlene periodically after her return and she required no further hospitalizations. She was compliant with taking her Lithium in spite of the development of some side effects that gave us both causes for concern. To the best of my knowledge she never again accepted an offer from the Designated Driver.

2007  

Carl Rogers and Steven

Carl Rogers and Steven

Carl Rogers was one of my teachers during psychiatric residency training.  I had been impressed by his books on psychotherapy and even more so by having had the opportunity to observe him interview patients (he called them clients and labeled his efforts as client-centered).  My psychotherapy supervisor was not Carl at the time I am about to describe, but he was one of his protégés.

Steven had been hospitalized after cutting his wrists in a suicidal attempt.  He was receiving antidepressant medication. I was designated to be his psychotherapist while in the hospital.  Staff had noted that he seemed to be bottling up his feelings and they thought this was impeding his progress in terms of lifting his depression.

So my goal in our first meeting was to facilitate the expression of thoughts and feelings that he had thus far been unable to share. I employed a Rogerian technique that consists of intense listening that allows for empathic responses that are just slightly exaggerated in their emotional content.  This resulted, when it worked, in patients being able to express themselves in progressively  “deeper” and more emotionally laden ways.  This was thought to increase self-awareness and provide relief.

In the client-centered approach the therapist avoided asking direct questions, limiting his or her responses to comments made by the patient wherever that might lead.  Midway into our first session Steven began talking about his relationship with his father and the conversation with his comments and my responses to them went something like this:

“My dad and I didn’t always have the best of relationships.”

“Sometimes you and your dad didn’t hit if off too well.”

“Sometimes I thought he treated me unfairly”.

“There were times when you felt he was treating you unfairly”.

“And when that happened I’d get a little bit irritated.”

“When that would happen it would tic you off just a little.”

“In fact sometimes it would make me feel angry.”

“Sometimes it would make you mad.”

“I’d even have revengeful thoughts.”

“You’d even think about how you could get even with him.”

“It got to the point I thought I didn’t really like him like I should.”

“It was hard to like him at the same time you felt so mad at him.”

“I could feel the angry feelings starting to build up inside of me.”

“Those angry feelings were beginning to boil up inside of you.”

“And my anger at those times would become awfully intense.”

“You would get madder and madder at him.”

“I’d feel like I couldn’t keep my true feelings from him anymore”.

“You felt like you were going to just explode and gush out your feelings.”

“At those times I actually hated him!” (This was said loudly and with a facial expression that matched his words).

My softly spoken and measured response:  “At those times you didn’t just feel irritated or angry or mad at him but it reached the point where you actually hated him.”

There was a pause and then he said, as if he were amnesic for what he had just told me, “What you are telling me is true.  I never realized it before.  There were times when I hated the son of a bitch!”

In retrospect I find it interesting that this Rogerian approach helped Steven to uncover feelings he had most likely denied not only to others but also to himself up until that time.  I also find it interesting that he owned his feelings right up to the time when they became so intense that it was easier to accept his final insightful leap as coming from his therapist (me) rather than himself.  Certainly this approach may also have encouraged expression of feelings that were exaggerated in degree. At any rate, Steven continued to improve during his hospital stay.  Subsequent sessions were much less dramatic but his responses to our meetings appeared to be positive.  He was receiving medication along with group and occupational therapies as a part of his treatment experience.  My interactions with him as a novice therapist may have been helpful. At least I am fairly confident that they did not make him worse.

2006     

Blanche

Blanche

My retirement was only a few weeks away and I was in the process of referring my patients to other psychiatrists. On this day I was meeting with Blanche.  I had been seeing her at approximately 3 month intervals over the past 20 years for treatment of a chronic depression following a hospitalization for a suicidal attempt.  Her affect was always severely blunted and she would look at the floor rather than make eye contact during our brief visits.  She volunteered little if any information on her own.  By her mostly yes or no and frequently mumbled answers to my questions, I was able to determine that she was not experiencing significant side effects from her medication, that she was not feeling sad or suicidal and that she was not experiencing physical symptoms of depression like insomnia, anergia, anorexia, psychomotor slowing, etc. 

I explained to her that I was going to retire soon and suggested that she choose another psychiatrist to monitor her medication.  I told her that two new doctors would be taking over the practices of my partner and myself.  I went on to describe them.  Dr. V was a young man who had just recently completed his psychiatric residency in a prestigious program and was especially well trained in psychopharmacology.  He was outgoing and informal in relating to his patients. He, for example, wore a sweater rather than a coat and tie. Dr. C was in his mid fifties and had graduated from Harvard Medical School.  He was formal and very professional in his dress and manner.  He was soft spoken and some people might find him difficult to relate to, at least initially.  He certainly was experienced, knowledgeable and a competent doctor.

When I asked her which doctor she might prefer there was a long pause and it did not appear she was going to respond.  So I said that based upon the fact that she had done well under my care over the last 20 years and the fact that I was probably more like Dr. V. than Dr. C. she might do best with him. 

For the first time in all the years I had known her, Blanche looked me straight in the eyes and with a firm, measured, clear voice said, “I’ll take the guy with the tie!”

2006

Mom (Gail)

MOM

My mother was the youngest of 5 daughters and often referred to being “spoiled” as a child. Her father, Hosea White was a country doctor, having completed his one year of training in Iowa, and was the first doctor in Brown County to make his house calls in a car rather than horse and buggy. Her mother, Harriet, was still living until I was 8 or 9 years old and I recall Sunday dinners after church at grandma’s house when she always made three kinds of pie; apple, custard and mince meat.  During those years she was living with my Aunt Kate, the Aunt I was closest to.

During her school years my mother was active in music, playing the piano for functions at school and church.  She later was a paid performer, playing the musical background for silent movies shown at the local theater.  This was accomplished without a musical score, constantly changing the music to reflect what she viewed on the screen.  She could play by ear but also read music easily and had the ability to transpose anything she heard to any key that was valuable when she accompanied singers with limited vocal ranges.  She played the organ at the Congregational Church on Sundays as well as for weddings and funerals.  When she got older she would sometimes find herself playing popular secular tunes by ear at funeral services (once it was “Mares eat oats and does eat oats and little lambs eat ivy”) but with sufficient vibrato stops pulled and in a style that made the congregation fail to notice it.  She also sang with nearly perfect pitch and a volume that caused her to be heard over others in the choir.  She gave piano lessons and unsuccessfully tried to teach me to play.  I never got past Thompson’s Third Book.  I was finally given permission to quit when my required practice time was pared down to one half hour session weekly and I waited until 11:30 PM on the last day of the week to fulfill my obligation. My capacity for passive aggression and stubbornness was even better demonstrated as an 8 or 9 year old when I sat at the kitchen table from noon until supper time when told I couldn’t leave until I ate one bite of cabbage. In retrospect this was basically the way I individuated myself from her along with becoming involved in many activities that kept me away from home much of the time during my school years.

I found some of her behaviors confusing and others without consensual validation.  We almost always attended the Sunday afternoon movie.  We would get there at least 30 minutes early so she would be able to choose the best seats.  She would then keep us moving to different spots right up until show time, never satisfied she’d found the best spot.  She bragged about her father being a physician, and later about my being a doctor to others but trusted her care to chiropractors and over the counter vitamins and herbs.  She insisted that I had uttered my first words before the age of 6 months, this story being bested by one about how my brother Bill’s dog, Skippy, had talked to her on many occasions. She was unable to understand my embarrassment when she invited the basketball coach to our house for an evening meal when as an underclassman she didn’t think I was getting enough playing time. She expressed anger that usually came about because she didn’t get something she wanted but wouldn’t say what it was, by becoming sullen and mute and taking to her bed.  I don’t recall her ever showing genuine vicarious pleasure in anything I did; rather her emphasis was upon how I might accomplish things for which I could and would someday publicly  give her credit.

With occasional ambivalence I sang at church and for weddings and piano recitals in addition to participating in band (percussion) and chorus at school. My mother would accompany me on the piano or organ for outside of school performances. After high school I dropped singing except for my freshman year in college when I was part of a small choral group and rejected further offers of mother son performances.  I still have occasional dreams in which I am visiting home, now an adult, and being coerced into singing at some type of gathering, being neither prepared nor willing to do so.  I do have pleasant memories of gathering around the piano at home with others and even alone to sing as a form of entertainment and I have pleasant memories of listening to my mother play. Money she earned giving piano lessons helped me through my first year in college.

In retirement years I would visit mom and dad at their trailer park in Mesa, Arizona.  It appeared she had made many friends there who appreciated her wit and flair for the theatrical that she put to good use at their community center.  She was also respected as an outstanding bridge player. 

So how did things get resolved in my sometimes complicated relationship with my mother?  Quite unanticipated by me it happened when she became demented and feeble over the few months prior to her fatal heart attack.  Suddenly the ambivalence cleared and it felt comfortable and natural to nurture her. Left far behind were any grievances I might have felt, not having felt loved by her in the ways I would have wished but simply in the best ways she was capable.  I can now see how my inability to please her probably increased my drive to excel in whatever I did.  My inability to understand her behaviors may have made me more inquisitive and scientific in my approach to my profession and almost certainly helped me to empathize with my more difficult patients. I inherited my intellectual capacities from her as well as whatever ability I have to write poems or prose.  The music she exposed me to formed the basis for the enjoyment in listening that has enriched my life.  She is part of me. 

September, 2002

  

Mame, Lila and Jessie

MAME, LILA AND JESSIE

They were known to me as Aunt Mame, Aunt Lila, and  Aunt Jessie.  Their father, Peter Davie McAndrew was an attorney. He was my dad’s Uncle. They lived in a big two story house on a large lot shaded by beautiful statuesque walnut trees that were inhabited by busy squirrels.   They were situated across the street from the Congregational Church about 3 blocks from Main Street  and two blocks south of HiWay 21.   The 3 sisters, the only children in their family, remained in the house in which they were raised and none ever married.  Jessie, the youngest, apparently had a serious boyfriend sometime in her early adulthood but the relationship didn’t last for reasons I never knew.  She was petite and attractive in photographs compared to Lila and Mame who were large and somewhat ungainly.   They all had professions. Mame, the oldest ran an abstract office.  Lila taught first grade.  She initially completed manual training which as I recall was a one year course after high school to qualify her to teach.  Over the years she took enough college courses to obtain a master’s degree.  She taught for more than 50 years and after her death a new grade school was built in Ainsworth that was named after her.  Jessie worked all her life in the Ford Garage.  She had an unusual memory for details and could immediately access any part needed for repair of any Ford product.  She was appreciated and respected by her boss, Frank Corbett and he and his wife Gertrude, their daughter Mary Ella and later her husband Paul and son Frankie were like family, sharing holiday meals with them, alternating hosting between houses.

Because they all worked full time they had a daytime maid, Emma, who cooked their meals except on holidays when they did the main dishes while she assisted them.  She also cleaned the house.  She lived a couple of blocks away in spartan quarters.  During my grade school years I ate my noon meals at their house, Jessie driving Lila and me to their house where we were met by Mame.  Emma served elegant meals.  Occasionally we would eat pheasant that hunters who had been Lila’s former pupils would bring.  Eating and as a matter of fact overeating was encouraged.  Emma, whom I admired, once told me how not finishing everything on my plate would somehow make me responsible for the  starving children in far away places like China.  To this day I feel compelled to finish whatever food I put on my plate.

Mame, Lila and Jessie, referred to by my parents as “the girls”, always spent Christmas Eve at our house, opening gifts that in my preschool years had mysteriously appeared via Santa Claus on our front porch before eating dinner after the church service.  We would go to their house on Christmas Day joined by the Corbett family and Chet Bowen.  I’m not sure but I think he was Mame’s friend that had grown out of the transactions between her office and the bank where he worked.   I recall being only a little bit bored  being surrounded by adults on these occasions.  They seemed to enjoy each other’s company and had favorite stories to repeat.  When the talk would turn to politics there would be general agreement that the country would be better off with a republican president.  When Harry Truman took office after FDR’s death this was seen as catastrophic.  He was perceived by the group as a puppet of the Pendergast Machine and their prediction of the future under his leadership was grim. Many of the pleasant memories related to these occasions are firmly connected to the food we enjoyed.  We would arrive through the front door that led directly to the dining room.  The table would have been elongated with slats made for this purpose and would be covered by a fine linen cloth. Napkins would be rolled up in their sterling silver holders.  An array of silver spoons, forks and knives would be in place in anticipation of the multiple courses that would be served.  Tiny spoons were laid along side little dishes which would be filled with cranberry ice to clear our palates between courses. On the buffet at the end of the room there would be an assortment of candies and nuts. The aromas emanating from the adjacent kitchen were exquisite, only slightly dominated by the turkey, it’s dressing and the freshly baked rolls.  After getting my small sampling of the turkey I would proceed to the back porch where the cranberry ice and mint ice cream were being made and I would get to lick the revolving wooden mixing paddles when they were done.  The quality of the food was matched by its quantity and I don’t think anyone ever left the table without the awareness that he or she had eaten too much.

The sisters were by our standard well to do but never ostentatious.  They would make a 285 mile drive to Omaha once yearly where they would buy the clothes they would wear to work and church the ensuing year.  Their house was always well painted and well carpeted. Jessie, the driver for the family, always drove a relatively new Ford or in the later years a Mercury. There was an undiscussed but definite attitude from my mother at our house that I should avoid receiving too much from them because that would make me, like my sister Jean before me, as my mother perceived it, beholden to them. Translated that meant that doing so would mean I liked them better than my parents. They still managed to express their generosity which was never with strings attached.  They on several occasions took me to Omaha where I saw an orthodontist who was correcting my overbite.  I remember their taking me to the Orpheum Theater where a vaudeville show would precede the movie.  I was enthralled by the crooners, comedians, magicians and soft shoe dancers that were  on stage.  They would patiently allow me to stay to see the live show that I had seen before the movie again after the movie had ended.  Later they gave me the money to buy a microscope that was required in my freshman year of medical school.  It was purchased from Ken Austin whose father owned the bowling alley and pool hall. He had graduated a year ahead of me in high school and had failed in his first year.  The microscope was interesting in that it was binocular in contrast to what most of the other students had that were monocular.  It was trade named Heidelberg suggesting that it had German optics but was actually manufactured in Japan and assembled and marketed in Los Angeles.  To digress still further, I sold it after my basic science courses were completed for enough to buy a spinet piano for Jane that would fit in our small apartment.  So they had given the gift that kept on giving. 

Mame died during the same year as  grandma Harriet and my brother Bill when I was nine years old.  Lila died when I was still in medical school.  Jessie  lived her remaining years in the house alone, self sufficient to the end in spite of a fractured hip which confined her to the main floor.  Her generosity continued and included giving us a loan which allowed us to build our new house before selling our old one.  She spent much of her time during her last days organizing her finances to make it easier to leave everything she had to my sister Jean and myself.  At the end she was hospitalized in Omaha.  I flew out to see her and was able to have an intimate conversation with her that included thanking her for all she had done for me and my family.  It was obvious at that time that she would not recover to the point that she would be able to continue living by herself.  We discussed the fact that we had a nursing home in Oshkosh that reserved beds for members of the PEO (she was a proud member) and the plan was for me to make arrangements for her to come here to Evergreen in Oshkosh.  Also in that conversation she indicated that the nurse had taken her diamond ring, her mother’s wedding ring, from her for safe keeping.  I talked to the nursing staff and insisted it be returned to her after they counseled me that she was intermittently confused and they were afraid it might be lost.  I returned home a few hours later and received a phone call that she had died.  I felt little regret when they said the ring had indeed been lost knowing that she had enjoyed having it on her finger during her last moments.  Jean and I attended the funeral in Ainsworth. The old church had been replaced by a new one but they did not have a full time pastor. The part time preacher directing the service had not known her and seized the opportunity to address the packed congregation regarding his views about who might be bound for the golden streets of heaven as opposed to those of us who were headed for hell and damnation.  

 For many years after Jessie’s death I had a recurring dream.  I would be visiting my parents or others in Ainsworth and inquire about  her well being.  No one would have seen her for quite some time and they would not be sure whether she was alive or dead.   With a mixture of angst and guilt I would go to her house that would be dark and quiet.  When I would find her she would appear ghostly frail. We would be glad to see each other again and our conversation would be warm.   

Dad

            DAD

It would be fair to say that memories of my dad are skewed toward the positive just as memories of my mom are probably distorted toward the negative.  He was my first caregiver, my mother having a prolonged stay at the hospital postpartum because of phlebitis of her lower extremities.  Of course I don’t remember those days of infancy but perhaps my perception of him as the most significant nurturing person in my life had its roots there.  A very early memory is bedtime when he would rub my back and hum or whistle “My Bonny lies over the ocean, my Bonnie lies over the sea...” I wasn’t very old when I realized that he was singing off key but that didn’t diminish my appreciation for the intimacy behind his song.

Born February 3, 1895, the youngest of nine children with a 25 year span between himself and his oldest sister Alice, he was raised on a farm near Ainsworth, Nebraska.  His father William Davie McAndrew was born in Glasgow Scotland 16 June 1843 and his mother Emily Dowding was born 18 October, 1852 in Whitshire, England.  Emily died in 1908 when he was 13 years old and William Davie died in 1919, with a note on his tombstone indicating that he had been one of General Sherman’s bodyguards during the Civil War.   My dad attended school in Ainsworth through high school.  He took one class during the fall after he had graduated in order to be able to play football for a fifth year.  He was the quarterback on the team and we still have the team picture in which he was the only one required or at least encouraged to wear a helmet.  Sometime in high school he began dating my mother, a relationship that was to last through more than 50 years of marriage.  He joined the army after the onset of World War 1 and was promoted to the rank of Sergeant.  He did not see combat duty but was stationed in France at the close of the war.  Rather than return home immediately he accepted an offer to act as chauffeur for two well -to-do gentlemen who toured Europe for the next 6 months. He often remarked how well he was treated by his employers who included him in all of their activities.  Soon after his return home he got a job as a mail carrier that he continued until his retirement.  He never complained even when he had to carry packages through unshoveled walks during the Christmas season.  He did, however counsel me on my way to college, “I want you to do whatever you want to do in life but since I’ve already done the mail carrier thing you might want to try something else.” At work he walked an average of 20 miles daily.  He took up golf when I was in high school and after work he would then carry his clubs and walk the golf course burning still more calories.  It’s not surprising that he was chronically trying without success to gain weight.  When it was nearly time to retire he sold the small farm where he had spent his early childhood and bought 80 acres of trees and an old farm house constructed with wooden pegs rather than nails near Evergreen, Colorado. He made the purchase because it was beautiful.  It later turned out to have been an excellent investment that made retirement financially comfortable.

My dad was a shy person who always managed to avoid being the center of attention and this meshed well with my mother who wanted to be constantly in that position. He was known as Honey in our immediate family and Jack by friends, both nicknames given him by my sister Jean; later called Pop by me and occasionally addressed by a relative by his real name Carl. His ruddy complexion, tendency to blush and shyness were all traits I inherited but over the years I overcompensated for the shyness part of the triad.  When I studied with Carl Rogers he described the characteristics that made psychotherapists effective in promoting emotional growth as attitudes conveyed to their clients or patients which included unconditional positive regard, empathy, and consistency (self congruence).   My dad conveyed these attitudes to me no matter what I said or did and that I think is why I loved him without ambivalence.  His shyness did not prevent him from being an active listener or from offering support.  I always knew there was nothing I could say or do that would lead to his rejection of me.  I always knew that he would vicariously experience my joys and successes while in no way using me for this purpose. 

One bond we shared was sports.  He spent endless hours playing catch with me with footballs and baseballs in early years.  Later he was the consummate fan when I participated on high school teams.  He got most excited about football since this was the sport in which he had excelled.  I don’t recall him ever criticizing my play and I’m sure I frustrated him when he would try to console me after a loss and I would be too much into sulking and self- recrimination to respond.  The only time he ever interfered with the coach was when I sustained a mild concussion that became evident to him when I momentarily lined up with the other team getting ready for the next play.  He insisted the coach take me out of the game to see what was wrong. 

My dad never read to me and I don’t recall him reading more than the local newspaper but he let me know that he was proud of my academic accomplishments and thought they were important.  He couldn’t carry a tune but he attended and seemed to enjoy every musical performance in which I participated.

One of my dad’s interests was inventing things.  The thing I recall was an airplane swing that used a stick to go up, down or side to side.  He was also fascinated with cars and was able to buy his first new car, a Ford,  just before the onset of World War II.  When new cars were no longer available and the value of his went up he sold it.  We then had a series of fun used cars that included a Chevrolet Coupe, a Willis and a Buick with a rumble seat.  

My love and admiration for my father was prompted less by what he did than by who he was. He was a gentle man, a kind man, a caring man, a man of unquestionable integrity.  He never expressed a wish for more than the life he enjoyed and his pleasures came from simple things like eating chocolate ice cream before bedtime.

After he had retired and he and my mother were living in a cabin near Evergreen, Colorado, we had an interesting talk in which he philosophized (not something he usually did) about how things were changing in our relationship.   He talked about how he had been the one for me to lean and depend on for so many years and how now he was feeling dependent upon me. He then began to tell me about the tangible things he wanted me to have after he was gone.  I couldn’t bear at that moment to contemplate his death and responded by saying these weren’t things I really needed.  Many times I’ve wished I could have that moment back again so I could show my appreciation.

And when he did die the experience was not what I had expected.  The dying part was the toughest.  He was in intensive care for almost a week, totally unresponsive after a heart attack plus a stroke.  With permission of sister Jean and my mother I talked to the resident doctor who was his primary physician and insisted that heroic measures to keep him alive stop.  His funeral was at a funeral home near the trailer park in Mesa, Arizona where he and my mother first spent winters and then took permanent residence.  During the brief ceremony a lady in back of the room cried and wailed constantly.  When the service was over I approached her and asked who she was, noting that on my several visits to the trailer park I didn’t recall having met her and that by her reaction she must have been very fond of my father.  She said she had never met him.  Turns out that what she did for entertainment was to go to the funerals she saw listed in the newspaper.  I found this as did my sister Jean to be very funny and we laughed as soon as we were out of her sight.  I was first surprised that I could laugh at the time of my dad’s funeral and then went on a brief guilt trip spurred by the thought that if someone had seen me laugh they would think I didn’t love or respect him.  I did think about him often in the following weeks and months and this would bring tears but not pain because the recall was of pleasant times shared.  To this day I occasionally have a dream that something really good has happened to me and or my family and I awake thinking I want to call him and tell him about it.  The tears are gone.