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

  “Wow,” I said astutely.

  A nurse walked by me, carrying parts of a metal IV pole. “Yeah, wow,” she said with a sarcastic snort. “As if I’m not busy enough, I gotta waste time pulling all this apart for our most frequent flier every time she decides she wants a little attention. It’s not like there are other patients of mine who are . . . I don’t know, actually sick or something. God forbid I spend my time doing things for them.”

  As the nurse passed, I stood there, amazed at the chaos that one person’s self-directed actions could cause. Each time Lauren swallowed a potentially dangerous object, she wielded her power to cause institutional upheaval and widespread personal disequilibrium. She angered nurses and surgeons; she sent administrators into flurries of paperwork; she prompted special case conferences and grand-rounds debates; she ignited infighting between medical disciplines eager to disclaim primary responsibility for her care. While hospitalized, she was rude and unappreciative at best, provocative and hostile at worst. She cost people time and money and patience. During one particular period, there was even a superstitious policy among medicine residents: They refused to say Lauren’s name aloud, lest doing so should conjure her to appear in the emergency room later that shift.

  I was not immune to Lauren’s maelstrom. Once she was admitted, I visited her room daily, attempting to engage her in any way I could. I tried to connect with her, at first naïvely and pridefully, hoping I could penetrate her caustic exterior and, in doing so, truly steer her toward health. During one visit I tried to offer her a chance to talk about the experiences that had led to her behaviors; during the next I proposed that we discuss coping strategies she could utilize when she felt the urge to swallow something. Despite the lengthy list of medications she’d tried, I went through them one by one with her, struggling in vain to discern whether any one of them had been more helpful than another. Each time I saw her, I endeavored to cajole her into seeing the benefit she would reap from committing more fully to the outpatient treatment that she would have after she was discharged. Perhaps, I imagined, my empathetic ear could succeed where so many others had failed. This fantasy, of course, was fleeting. Some days she ignored me; others she tore into me in a fit of rage.

  Lauren met each of our encounters with derision. Although I typically felt composed and in control during clinical meetings with patients, working with Lauren made me feel inept. I couldn’t even reasonably call it “working with Lauren.” I was floundering, and I was sure she could see it. No matter how steadily I attempted to keep my cool, I began to feel that Lauren could sniff out my discomfort. As a psychiatrist, I felt confident in my ability to make patients feel calm and safe in my presence. But Lauren’s turmoil wouldn’t steady. Rather than providing her with security, I felt as though I were absorbing her unease. And the more wobbly I felt, the more emboldened and unwavering her aggressive stance became. My savior fantasies vanished, and I began to dread my daily obligation to round on her.

  One day Lauren was particularly nasty to me. Early in my psychiatric training, I learned that mentally ill people can harbor an uncanny ability to detect—and then broadcast—a person’s most exquisitely sensitive vulnerabilities. During my first week as a psychiatry resident, I shuddered as an agitated, psychotic woman screamed a series of vile racial epithets and accusations at the security guards who had restrained her and were carrying her to the seclusion room. A month or two later, I treated a demented man who routinely approached a nurse who, unbeknownst to him, was a rape survivor; he ranted through a litany of aggressive and explicit sexual acts he said he intended to force upon her while she slept. A friend and colleague of mine, besieged by guilt after his depressed mother committed suicide, had a therapy patient who knew nothing about the death and yet began leaving my friend daily voice-mail messages saying that she was going to kill herself and, if she did, that it would be my friend’s fault because he did not save her.

  A mentally ill person’s accuracy in hitting the mark could be mere coincidence. Or there may be a kind of perceptual acuity that sharpens in the dangerous throes of madness, as hearing or eyesight might in a life-or-death chase. Without excluding those possibilities, I have come to think of this form of cruelty as a combination of disinhibition and powerlessness. The social filter that prevents a person from saying wildly inappropriate things can dissolve when the mind is sick. And any animal, when it perceives itself to be cornered and in mortal danger, desperately lashes out in the way most likely to make its aggressor retreat. And so in the cases of people who are psychiatrically ill, the ferocity is not so much a character trait of the person doling it out. The ferocity is rather a symptom, brought about by the stark territory of mental illness and its lonely, fearsome landscape.

  In Lauren this vitriol came at me after days of the silent treatment. Dutifully, if halfheartedly, I knocked on her open door one late afternoon. “Lauren? It’s Dr.—”

  “I know who the fuck it is,” Lauren interrupted. She sat up and began to address the two security guards at her bedside, gesturing toward me. “This fuckin’ Amazonian joker comes in every day with her overgrown, ugly-ass eyebrows and talks to me like I’m a two-year-old just so she can feel like she’s saving the world and write some bullshit nonsense in my chart about how my psych meds need to be changed.” My stomach—within my six-foot-tall frame with its badly untended eyebrows—dropped. Had I been condescending to her? Had I gotten carried away with narcissistic fantasies?

  “She has no fuckin’ clue what to do with me, so she goes all rich-girl-who-went-to-Brown, ‘Let’s talk about some healthy ways to handle your feelings’ so she can get out of here, dope me up on more of those horse pills, and tell everybody she’s a fuckin’ regular Dr. Phil!” The guards looked toward me sheepishly for a response.

  “Well . . . at least you’re telling me how you feel,” I stammered, trying to gauge whether or not I was blushing. I wondered if Lauren and the guards all thought that I was as inept as she was making me out to be, as inept as I suddenly felt.

  “‘At least you’re telling me how you feel,’” Lauren mocked in a whining singsong. “Get the fuck outta my face, Amazon Brown.”

  I felt both humiliated and relieved. She was giving me a way out. “I’m not going to force you to talk to me, Lauren,” I replied.

  “No, you sure as hell are not,” she shot back.

  “But I really am trying to be helpful to you,” I said, turning to leave the room, “and I’m happy to talk later if you’re feeling more up to it.”

  As I passed through the door, she let loose with a final arrow. “Don’t hold your breath. Maybe use the time instead to get you some tweezers.”

  As I walked away, I heard one of the guards whistle softly and let out a giggling “Damn!”

  • • •

  During my third year as a medical student, a notoriously demanding and demeaning surgical attending physician had gathered a group of us together to ask for feedback on our experience of the surgical clerkship. Though we had all found it both unnecessarily grueling and poorly organized, my peers dutifully offered enthusiastic praise as the attending went around the table, soliciting comments. When he reached me, last, I offered constructive criticism that was honest and fair. He was silent for a moment and then responded.

  “I don’t know what you’ve heard about how you’ll be graded in this clerkship,” he began quietly, and then gestured to his shoes. “But these are the feet that are connected to the legs that are connected to the ass that you should be kissing right now.” He paused for effect, then continued. “Do you want to rethink your feedback?”

  At the time I was deeply humiliated and enraged. Yet by now I had all but forgotten about him. However, in the midst of my treatment of Lauren, I had a dream that I was a medical student again, assisting that same antagonistic surgeon in an operation. In the dream I was standing beside him, holding retractors and looking into the open cavity of the patient’s
body. The patient was a woman, and the surgeon was pulling her intestines, hand over hand, as if he were reeling a boat in to shore. I was gripping the retractors, but my wrists were starting to fatigue. A strand of hair fell into my face, and I brushed it away with a finger and then held the retractors again, contaminating the sterile field. I knew I had inadvertently placed the patient at risk for infection but was too afraid to say so. Why? Afraid of what? I thought, This is ridiculous! This operation could fail. This patient could die, and why? Because I’m embarrassed that I made a mistake? Because I don’t want this guy to yell at me? Emboldened, I turned to confront the surgeon, but it was too late. He was gone. I was alone in the room with Lauren, who lay on the operating table, her abdomen agape, holding a needle and thread out to me. “Go on,” she said. “Close me, Amazon Brown.”

  Waking from the dream, I understood my discomfort with Lauren more deeply. My work with her felt futile. She was making me feel futile. Rather than engaging with and exploring that futility, it was simpler, and more fun, to join in the pervasive jokes about zippers and not lending her my pen. Lauren’s inexplicable behavior invited this kind of avoidant humor. To look closely at the emotional circumstances that would bring Lauren to swallow a horrifying array of objects demanded a steady gaze fixed firmly on her suffering. Where was the fun in that?

  In her riveting book Swallow: Foreign Bodies, Their Ingestion, Inspiration, and the Curious Doctor Who Extracted Them, Mary Cappello cites a 1930s article from Literary Digest about the intentional ingestion of inedible objects. Its tongue-in-cheek title is “Iron Rations: Fakirs Swallow Swords, but Amateurs Take Cake Lunching on Hardware.” Cappello describes the article as “a jaunty piece of journalism that presents the patient, Miss Mabel Wolf, as an amateur when compared to a knife-swallowing Indian magician, but one whose staggering feat far outstrips his. Each sentence is accompanied by a wink and a nudge as if to admit the extremity of her act while keeping all that is disturbing about it at bay. . . . ‘When she felt depressed,’ the journalist jokes, ‘she cheered herself up by indulging in a little nut-and-bolt snack.’” In all, Mabel Wolf had swallowed an astonishing array of objects over time—1,203 to be exact—an array that included various tacks, screws, bolts, pins, nails, beads, pieces of glass, and safety pins, as well as a coat hanger and the handle of a teacup.

  Groaning about Lauren’s chronic condition (“a little nut-and-bolt snack”) aligned me with my colleagues and the other medical teams. It subconsciously shifted the balance. It became us against her, and there was strength in numbers. If we all knew that Lauren was crazy, then what did it matter what insults she flung my way? If Mabel Wolf was a hysterical depressive, she could be relegated to the circus tent of oddballs and freaks (and sword swallowers!) and the sane readers of Literary Digest could disclaim any similarity between her suffering and their own. On the hospital wards, the jokes about Lauren provided a kind of shared solace. They allowed us to dismiss her as a hopeless case. They quietly identified her as the doctors’ adversary rather than a hospitalized patient no less in need of our care than any other.

  The increasingly obligatory nature of my visits to Lauren was a sign that more than anything I was ready for her treatment to end. Like my medical and surgical colleagues, I just wanted Lauren to be well enough to leave the hospital. Unfortunately for both Lauren and her doctors, it was clear that being “well enough” to be discharged from the hospital was a fleeting, ever-changing condition in Lauren’s case. Her recurrent, crisis-driven visits to the emergency room and subsequent admissions inflamed a mounting feeling of resentment in her care providers. After Lauren had been discharged and readmitted several times, the medical and surgical teams wanted more than for her to be discharged from their care yet again—they wanted her to be out of their hair for good.

  The resentment that Lauren’s swallowing bred was mostly directed back toward her. But occasionally the adversarial stances seeped into the ways the medical teams related to one another. One day, outside Lauren’s doorway, I ran into the rounding fellow of the GI service.

  “Hey,” I said, stopping him in the hall, “I saw you guys finally got the last of those bulb fragments out, so she’s probably pretty close to being able to go from a medical standpoint, huh?”

  He turned and looked at me. “You know,” he began, “every time she comes in, you guys tell us there’s only so much you can do. We pull out whatever life-threatening thing she’s decided to eat this time, and as soon as she’s medically cleared, you let her go right back home so that she can shove something else down her throat.”

  “Well, yeah,” I said. “I mean, we can’t exactly keep her here once she’s not in danger anymore.”

  “Not here,” he replied, gesturing down the hall of the medical floor. “She should go to Jane 5. And once they won’t keep her anymore, she should go to Slater and stay there.” He turned away from me and continued on his rounds, down the hall. Jane 5 was the inpatient psych ward within this medical hospital; the doctors there had admitted and treated Lauren countless times before without significant improvement. They—and we—now felt that constantly admitting her to the psychiatric ward was counterproductive, because it simply extended the duration of her hospitalization and any attention and reinforcement she received from it. Once she was discharged, she had proved to be no less likely to swallow something. And Slater? That was the state mental hospital. The fellow was arguing that Lauren be permanently institutionalized.

  I was taken aback by this doctor’s suggestion, but in truth his urge to have Lauren put away and prevented from coming back to his service was not too different from my own obligatory visits to her, my avoidance, my wanting her to get just better enough to leave. He made his wish more overt, but, whether or not I was willing to admit it, I shared that desire. I had given up any faith in the possibility of a meaningful recovery for Lauren, one in which she would stabilize and break her cycle of emergent hospitalizations, in which she would find and employ healthy ways of coping with her distress. My anticipation of her discharge did not mean I had some fantasy that she would get better once she left. It was a marker only of the fact that I wouldn’t have to be involved in her care any longer.

  • • •

  Sigmund Freud famously identified a number of psychic defense mechanisms—ways in which we unconsciously protect ourselves from being fully aware of thoughts or feelings that are unpleasant to us. Among them is projection, the ego defense in which, rather than acknowledging our own unsettling feelings, we assign them to someone else. Freud’s classic example of projection is a spouse (A) who has thoughts of cheating on his partner (B). Instead of dealing with those thoughts, which he finds repugnant, A unconsciously projects his feelings onto his partner, who he becomes convinced may be considering having an affair. By projecting “his own impulses to faithlessness on to the partner,” Freud says, A achieves “acquittal by conscience” and protects himself from consciously acknowledging his own thoughts of infidelity—a prospect he cannot tolerate.

  The famed psychoanalytic thinker Melanie Klein broadened and deepened our understanding of projection. One of her important contributions to object relations theory, the analytic school of thought for which she is best known, is the concept of a defense mechanism called projective identification. Projective identification is related to projection—as a wizardly cousin of sorts. So take again Freud’s example of A, the spouse with unfaithful longings. In order to distance himself from his unbearable feelings, A projects them onto B. In projective identification, B, the unsuspecting partner, is initially accused of infidelity without any grounds whatsoever. Over time, however, A’s relentless mistrust and jealousy create a distance between the two. B begins finding A irritating and unattractive. Eventually B does begin to imagine leaving A for someone who is more alluring and less suspicious. Hence the wizardry: In projective identification the distressing impulses within one person are displaced—projected—onto another person and thereb
y created within that second person. The dynamic is not magical, of course, but it is powerful, and usually incomprehensible to both members of the dyad because the forces at play are largely unconscious.

  I began to understand that projective identification was lying beneath and giving rise to a slew of reactions to Lauren: mine, the medical and surgical teams’, the nurses’, the hospital’s. Her swallowing and her subsequent desperate need for care and attention were always accompanied by her complete disavowal of her deep and persistent need for human responsiveness. Lauren sought care from doctors and nurses—professionals who had chosen to provide care and service to others and who wanted to do so. Then, after seeking our care, Lauren lashed out at us, often by identifying something in us that was actually real. My eyebrows, for example. My height. My privileged place of medical education. Amazon Brown. It was this aggression, based in some piece of reality, that hooked us into enacting the script of projective identification. Thus we became angry and abandoning figures who could only harm and disappoint, and in so becoming we enacted and reenacted the traumatic themes of anger and abandonment that had run in swift and ceaseless currents through Lauren’s life.

  As it does for many people who injure themselves, swallowing dangerous objects somehow brought Lauren a sense of calm when her life felt too chaotic, when she felt vulnerable and attacked. By her swallowing, and the way she treated the doctors obliged to care for her in light of it, Lauren projected her feelings of chaos and inadequacy onto all of us. The results were everywhere, from the swirling mess of staff members angrily dismantling a hospital room in preparation for Lauren’s admission to my own self-consciousness, self-doubt, and wish to see her discharged and gone.