Falling Into the Fire: A Psychiatrist's Encounters with the Mind in Crisis (17 page)

And yet there is a line beyond which transformation can lead to upheaval. On the other side of the line is illness. Determining the moment at which this line has been crossed is difficult and inexact. As a psychiatrist, I cannot practice in hindsight. I must balance the benefits of early, preventive care with the preservation of my patients’ civil liberties and choices. Often I see patients immediately after their illnesses have thrown them deep into the wells of personal devastation. But on rare occasions I see patients just
prior
to when the devastation is set to begin. In those cases, how can I preserve their autonomy up to that mythical line and then jump in to treat them precisely in time to prevent them from wreaking total havoc on their lives?

As an example, I recently treated Monica, an undergraduate honors student who had chosen to film a documentary on homelessness for her senior thesis. She began by forging a connection with a clergy member who helped run a local women’s shelter. With the help of that mentor, Monica arranged interviews with shelter residents. However, as the stresses of senior year increased, she began to feel increasingly behind. In order to stay up late to study and finish work for her other courses, Monica began taking pills from a bottle of prescribed amphetamines her roommate had for ADHD. She began sleeping less and studying more. She continued to take the pills to keep up. Soon she was even more deeply impassioned about her documentary project and felt it had the capacity to ignite real social change. Her professors, her friends, even her parents were impressed by her newfound energy and her urgent conviction to do good. Before long she found she did not need the pills to stay awake. She stayed up for days at a time and hardly needed to eat. Determined to get to the “real” story of the experience of homelessness, she began working without her mentor and accompanied women, and eventually men, to spend nights with them on the street. When she began not returning home at night, her college roommates became concerned and called Monica’s parents, who flew in from Texas. Her parents discovered that during the previous two weeks Monica had covered her body with tattoos and had had sex with multiple strangers, all of which she viewed, at the time, as a means of connecting with the people whose plight she was trying to shed light upon. They immediately brought her to the psychiatric hospital. It became clear, as my colleagues and I evaluated and treated Monica, that her fiery enthusiasm for her project had been the harbinger of a manic episode, brought about—or unmasked—by her use of stimulants. Her dedication to her cause had initially seemed so inspiring, like an awakening. Sadly, the awakening turned out to be a part of her illness, and it fueled her self-destruction.

When I met with Monica’s distraught parents, her father asked in desperation, over and over, “Should we have known? When she called us so excited, should we have . . . ? How did we let this . . . ? When should we have known?” If they had known, I reassured them, they would have intervened. But his desperate question was the very one I sometimes ask myself: At what point can we
know
that ecstasy, or singular purpose, or religious fervor has become pathological, if we don’t wish to wait until obvious and irreversible damage has been done? Why subject someone to the risks and potential adverse effects of medicine if her precise diagnosis has not yet been determined? The answer is that this anticipatory, proactive treatment is a fundamental and accepted component of every field of medicine.

When a woman feels a lump in her breast, she does not know what it is. It could be a benign, monthly, cyclical swelling, or it could be a malignant tumor that has already widely metastasized, or anything in between. To zero in on a diagnosis, her doctor may first order imaging—mammography or ultrasound, for instance—to attempt to determine what the lump is. If enough ambiguity remains after imaging, more invasive procedures are conducted: needle biopsies, lumpectomies. If those procedures reveal cancerous growth, still further procedures, such as mastectomies and lymph-node dissections, are routinely conducted to determine whether the cancer has spread. Mastectomies are often done on the basis of a cancerous lump that has been removed, regardless of the fact that there are no signs of cancer in the remainder of the breast. Breasts are even removed prophylactically for some healthy, cancer-free women whose genetics put them at high risk of eventually developing the disease. Women whose cancer has been treated, who have had mastectomies, who have undergone chemotherapy and radiation, who have no detectable cancer in their bodies, may for years still be prescribed medications whose risks and significant side effects are tolerated and endured because the medications have been shown to reduce the odds of breast cancer’s recurrence.

In medicine we constantly choose between two evils. We eye the balance, and weigh the risks, and make judgment calls, and predict as best we can. Whether our data include tumor markers and pathology results or a collection of mood symptoms and behaviors that indicate a dramatic change, we are trained to be vigilant but not hasty, to be proactive but not rash. Physicians prescribe medicines in order to ward off cancer recurrences and heart attacks and strokes and diabetes without knowing for sure whether these conditions would ever befall our individual patients if we left them untreated.

Similarly, I do not wish to medicate people who are simply joyous, or loving, or energetic, or passionate. Still, I cannot ignore that the stakes are high if I misread mania for ecstasy or psychosis for divine connection. So I trust in my study of symptoms and the diseases they portend. I question my intuition rigorously and routinely, but I rely upon it nonetheless.

•   •   •

F
or our tenth wedding anniversary, Deborah and I leave our children with a beloved baby-sitter and return to the Vermont inn where we were married. The four-hour drive from our home, which might have been onerous before we had children, is now a blissful chance to catch up and gossip and pontificate. As I look out the window at hills and hills of trees sliding past us, their leaves beginning to break into the colors of flame, I find that I’m thinking about a question the psychiatrist and philosopher M. O’C. Drury posed about Joan of Arc. “Supposing Robert de Baudricourt had been able to give Joan a stiff dose of phenothiazine instead of the panoply of a knight at arms,” Drury asked, imagining that today the saint’s holy visions might be treated with an antipsychotic, “would she have returned in peace to the sheep herding at Domremy?”

“What
about
Joan of Arc?” I ask Deborah, sharing Drury’s question with her as she drives. “I mean, if I saw someone today with her exact story—message from God, mission to overthrow the government, the whole deal—I don’t think there is any way I would come to any conclusion
other
than that she was psychiatrically ill. In fact,” I add, “I think the same can be said for a whole number of saints and martyrs who saw visions, or flagellated themselves, or fasted for prolonged periods of time. If I saw that today . . .” I trail off.

“But if you saw someone with those symptoms today,” Deborah says, “and they seemed to you to be at risk, or suffering, are you saying you think you’d be wrong to treat them?”

“No,” I say. “I think I’d be right to treat them. But what does that mean? Does that mean that psychiatry leaves no room for divinity? That we’d medicate a person out of what could otherwise be a transformative and saintly life? That we’d subjugate—or, worse, block—some message from God?”

“Seriously?” Deborah asks.

“What?” I say.

“Seriously? You’re worried that you are somehow blocking God’s communication to the world?
Now
who’s paranoid, or grandiose, or whatever you call it?” It takes me a minute to see that she is not just teasing me, that she is also—as always—very wise. She is pointing out my overly narrow assumptions about the possibilities of divine experience. “If there is a God—and you know I’m not sure about that,” she continues, “but if there is, don’t you think that how God reaches us today would necessarily look different than it did in the fifteenth century? And that God would find a way to communicate his message that wasn’t thwarted by your little pills?”

I start to grin. “You mean Big Pharma can’t kill God?”

“Yes,” she says, grinning with me. “That’s exactly what I mean.”

•   •   •

I
still wonder what has become of Colin. I think about my fear of him that first night in the ER as he stared at me and then my imagined diagnoses for him from the photo only, both of which pegged him as angry or dangerous. Knowing what I do now about his expansive happiness and joy, I wonder if something about that much openness—that willingness to really look with love at each of us—was somehow, on some deep level, actually unsettling.

I know that my fear is that today Colin is lost somewhere with full-blown psychosis, that his happy delusions have turned to horror, or, worse, that he resumed a spiritual fast that his body eventually could not withstand. Still, I understand the urge to hope that there are people like Colin whose symptoms do not necessarily indicate a debilitating illness but rather a prophetic gift or a deep connectedness to the world.

The romantic interpretation of mental illness gets it wrong. As difficult as it is for me to medicate someone who is doing no harm, who speaks of love and connection and ideas to which we should all aspire, I know, as a physician, that Colin is ill. That too much elation
is
a chimera. But that doesn’t mean that those of us who treat patients in the grip of madness do not hear and receive some piece of the messages they give us, even if those messages are rooted in psychosis.

I have stood before Caravaggio’s
Taking of the Christ
and felt some piece of myself disintegrating. I have believed something so deeply that I would like to wrap myself in bedsheets and proclaim it from the village square.

Every diagnosis is an act of faith. I trust my own clinical intuition and acumen. That does not mean I do not harbor some uncertainty about whether my judgments are, in the end, the right ones. I
am
certain, however, that in my work I am not trying to diminish my patients’ capacity for fervent belief, or creativity, or even eccentricity. Sometimes there is beauty or inspiration in the extraordinary experiences of my patients’ lives. More often there is agony. Either way, by the time they come to me, their beliefs or behaviors have begun to threaten their abilities to survive in the world, flawed place that it is.

“This hospital, like every other,” Annie Dillard writes, “is a hole in the universe through which holiness issues in blasts. It blows both ways, in and out of time.” She is writing about a medical hospital, about births and deaths, the comings and goings of life, the beginnings and ends. Yet she specifies—a hospital
like every other.
Like my own. I believe that healing is a kind of holiness. But like any good religion, it leaves me with a fair number of huge and unanswerable questions. The wind blows in. The wind blows out. Above my computer, pinned to a bulletin board next to artwork my children have made for me, a photo of Amma the Hugging Saint beams down at me. Her face is full of abundant and ubiquitous love.

I’ve Hidden All the Knives

I will not let them live for strangers to ill-use,

To die by other hands more merciless than mine.

No; I who gave them life will give them death.

Oh, now no cowardice, no thought how young they are,

How dear they are, how when they first were born—

Not that—I will forget they are my sons

One moment, one short moment—then forever sorrow.

—Euripides,
Medea

I
’ve hidden all the knives,” Anna said quietly. She and I had just sat down together in a small interview room on the inpatient psychiatric unit, where Anna had been admitted the night before. I hadn’t even had the chance to ask my standard opening question about how it was that she had come to be hospitalized. She looked into her lap as she spoke, and she looked miserable. “My son is fifteen months old,” she began. “And lately we’ll be in the living room and he’ll be watching cartoons and I’ll see myself . . .” Her voice grew fainter, then trailed off. I urged her to go on.

“See yourself what?” I asked gently. She glanced up at me, and I could see that her eyes had reddened and filled with tears. Her right thumbnail was digging deeply into her left index finger’s nail bed. There was a small, bright spot of blood. She took a deep breath and looked straight into my eyes.

“Drowning him. Or taking a knife,” she said, still quiet but now firm. “Slitting his throat.” Her gaze stayed on me. My stomach turned; I hoped my face did not betray the way I felt.

Over the years of my training, I have learned the potency of the first words I say to patients after they tell me their central concern. Even the most psychotic patients can retain the human capacity for gauging their listener’s response. Often it’s a test. A delusional patient may tentatively reveal that the same black van has been behind him in different cities, morning and night, to see whether his fears are dismissed or taken seriously. A pedophile may explicitly describe his fantasies to see how easily you can be shocked, or scared away and led off course. Regardless of the literal content that is disclosed, it seems to me that in such situations the real question these patients are asking is almost always the same: How well can you tolerate my suffering? How well can you sit with the pain?

Nothing about Anna made me feel as if she were trying to shock me. In fact, to the contrary, she seemed as if she had summoned up enough courage to tell me the truth and now was terrified about what I might think of her and of the horrific vision she had conjured. I imagined that if Anna were to tell her family members about these thoughts, they would immediately and appropriately shift their concern to the child. My own thoughts reflexively ran toward him, too. However, it was my job as Anna’s psychiatrist to focus on how these visions were affecting
her.
Still, I was better able to do so because Anna was on a locked ward and thus posed no immediate threat to her son.

Her eyes remained on me. I weighed my response. My gut told me that I could empathize with Anna, with how frightening and disturbing it must be for her to have those thoughts. And yet offering that kind of opening might close her down in the event that I was wrong. If I said, as I felt inclined to do, “That must be very difficult for you,” and in fact part of her shame lay in the fact that she was
not
feeling disturbed by the thoughts, then my assumption would only compound that shame and diminish the likelihood of her telling me how she truly felt.

“What has that been like for you?” I finally asked. She looked at me with incredulity.

“What do you
think
it’s been like for me? It’s absolute hell! I’m constantly feeling afraid that I might hurt him. And then, I mean, what kind of a mother . . . ?” And here she trailed off once again, tears slipping down her cheeks into the pursed corners of her lips.

“Have you been able to talk with other people about this?” I asked her, sensing from her question that the degree of shame might have prevented her from sharing her fears with anyone who could potentially be a support to her.

“Not in so many words,” she replied. “I think my mother-in-law is convinced that I didn’t really want to be a parent. I’m always asking her to come by and watch the baby, to take him out whenever I’m alone with him. I always make it sound like something urgent has come up, but”—and here she allowed herself a small, self-aware smile—“there are only so many things I can invent that require me to run an errand by myself or be at home alone. She has to be catching on that something is up. I even try to rotate. Sometimes I call my sister, but she’s so busy with her own three kids that I feel guilty. I mean, I can’t even handle one—how can I ask her to take care of her family and my baby, too?”

Anna’s desperation and shame were unmistakable. Yet I still didn’t have a clear picture of what she was experiencing when these images came into her mind. I picked up her pale pink hospital chart from the rolling rack beside my chair and quickly paged through it. When I came to the doctor’s notes from Anna’s evaluation the night before in the emergency room, I took a moment to read through them.

“This is a thirty-four-year-old married female who self-presents seeking help for what she describes as ‘the urge to kill my son,’” the emergency psychiatrist’s intake form read. “The patient is also having thoughts of killing herself.”

As Anna gingerly continued to talk with me, she eventually elaborated upon what I had found in the chart, though she did not look at me as she spoke. For the last six or seven days, she said, she’d had visions of drowning or stabbing her son, accompanied by voices telling her to see what it would feel like to hold the child underwater. These voices and visions were now coming many times a day, sometimes even multiple times an hour.

I knew I would meet daily with Anna while she was hospitalized and that I would need many sessions with her to more fully understand what she was going through and in what context these symptoms were occurring. Still, in this first meeting, I went through a relatively standardized set of questions and topics to try to learn more about her: Had she ever been to a psychiatric hospital before? (No.) To her knowledge, did anyone in her family have any kind of mental illness? (There was an uncle who’d been depressed and another one who drank too much.) Was there ever a time that she had felt that drugs or alcohol were a problem for her? (She got pretty drunk a few years ago on New Year’s Eve, she said. Did that count, if it was only once? No, I said. Then no, she said.) Eventually, with the basic initial questions covered, I returned to the issue at hand.

“I can hear how upsetting these last days have been for you,” I began. Then, gently, “How likely do
you
think it is that you might actually hurt your son?”

Anna closed her eyes, then opened them and refocused on the corner of the room beyond my chair, where the gray-painted cinder-block walls joined each other and met the floor.

“I don’t want to hurt him,” Anna said, beginning to cry. “I’m just so afraid I might get worn down and give in.”

“Give in?” I asked.

“To the voices, to that urge.” She paused, but I could tell she had something more to say. She took a few breaths, bit her bottom lip, and looked up at me. “I’m not the kind of person to commit suicide,” she said. “I don’t want to, and religiously, I believe it’s wrong.”

“Okay,” I said, waiting to hear where she would go next.

“And it’s not like I’ve been planning how I would kill myself or anything. It’s just . . .” Her crying turned to sobs. “I don’t know how much more of this I can stand.”

Once I finished my initial meeting with Anna, I returned to the nurses’ station to write in her chart. Immediately the unit staff circled me and talked over one another: Was I sure she had told me everything? Did I realize she wanted to see how it felt to drown her baby? Did I think she was trying to get attention, or was she really that screwed up? They made their collective opinion clear: They had seen all kinds of patients working on a psych ward, but Anna was dangerous and her symptoms were particularly galling.

Eventually Dawn, the formidable and unflappable nurse in charge of the unit, made her way toward me, and the circle dispersed. Only one day earlier, I had seen Dawn march down the hallway addressing multiple patients’ problematic symptoms quickly and effectively without slowing or missing a step. “Kevin, pull up your pants,” she said to a patient who commonly masturbated in public. “Susan”—and here she addressed a woman who was admitted time and again for cutting and burning herself—“by hitting the wall, you’re telling us you don’t think you’re safe to go out on the walk with the rest of the group.” Dawn was a real veteran, and despite my medical degree she clearly outranked me in clinical experience. When she had something to say to me, I listened.

“That Anna freaks me out,” she said quietly, leaning over the desk beside me. “I hope you’re not thinking of sending her back home with her kid. I’d hate to be the one with that hanging over my conscience.”

I hated it, too. But I also knew that it is more common than one might think for mothers to have thoughts of killing their children. A 2008 article in
Comprehensive Psychiatry
revealed that in a study of mothers of children under the age of three, 7 percent of nondepressed mothers had thoughts of harming their children. In the group of mothers suffering from depression, that number shot up to 41 percent. In a sample of mothers whose infants were colicky, 70 percent experienced “explicit aggressive fantasies” about harming their babies. Twenty-six percent of the mothers reported that during episodes of colic they’d had thoughts of killing their children.

Despite my knowledge that many women have these thoughts and few actually act on them, listening to Anna raised in me a mix of emotions, not the least of which was fear about her eventual day of discharge.

•   •   •

O
n June 20, 2001, Andrea Yates called 911. She told the police that she had killed her five children, ages six months to seven years. When the police arrived at her house, she led them to the bodies of her children, whom she had taken one by one to the bathtub and drowned. Despite years of inpatient and outpatient psychiatric treatment—and indeed an appointment with her psychiatrist to which she had gone with her husband only two days before the murders—Andrea Yates succumbed to a series of delusions about herself and her children. A retrospective 2009 article in the journal
Psychiatric Times
reports, “Ms. Yates experienced both depression and psychosis. She believed that her house was bugged, television cameras were monitoring her home, and that Satan was literally within her. She became convinced that her children were not righteous and would ultimately burn in hell. She believed that she needed to kill her children before [they reached] the age of accountability [in order] to save their souls.” The extent of her delusional belief system was obviously not clear to her psychiatric providers at the time, or to anyone else who might have been able to intervene and thereby save the lives of the five children. How, then, could I possibly reach a point with Anna at which I would feel confident sending her home to be with her son?

Without a scientific test to determine whether Anna might be a danger to her son, I needed to better understand her symptoms, so I could determine a more precise diagnosis and treat her accordingly. I needed to talk in depth with her and with her family members to get a clearer picture of what Anna’s life had been like recently. I needed to establish and be a supportive relationship for her. Most important, I needed to determine whether Anna fit the profile of someone who
might
murder her child.

We do not know much about women who kill their children. Forty years ago there was almost nothing on the topic in the scientific literature. In 1969 the American forensic psychiatrist Phillip Resnick conducted the first review of the world’s literature on child murder. Resnick scoured reports from 1751 to 1969 and found only 155 published cases. (The small number of historically published cases was not an indicator of the infrequency of the killing of children but more likely a testament to how irregularly such incidents were documented. We now have far more data. In fact, the U.S. Department of Justice estimates that, on average, 256 American children were killed by their mothers every year from 1976 to 1994, or one child every thirty-four hours.)

In an attempt to better understand the motives that could lead a mother to kill her child, Resnick proposed a means of categorizing these cases. He first divided them based upon the age of the child and in doing so designated 24 of the cases as “neonaticides,” or killings of children less than twenty-four hours old. The remainder of the cases, in which the children who died were more than one day old, he called “filicides.” To further underscore the relational factors that distinguish the two, he writes, “One is the killing of an unwanted neonate within the first few hours of life. The other is the murder of a child after its role in the family has been more fully established.”

Although Resnick went on to publish a paper the following year that reviewed what was known about murders of newborns, this first seminal paper focused only on the 131 documented filicides. It was called “Child Murder by Parents: A Psychiatric Review of Filicide,” and despite the four decades that have passed since its publication in the
American Journal of Psychiatry,
Resnick’s classification by apparent motive—the first taxonomy of any kind for these unthinkable acts—remains highly utilized today.

The article established five categories of filicide: accidental, spouse revenge, unwanted child, acutely psychotic, and altruistic.

Accidental murders of children arise not from homicidal intent but rather from abuse or neglect of a child that inadvertently results in the child’s death. A pediatrician colleague shared with me one such case she had recently seen in which a mother became drunk and fell asleep on top of her baby while wearing a down coat. She awoke to find the baby not breathing and without a pulse.