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