Falling Into the Fire: A Psychiatrist's Encounters with the Mind in Crisis (6 page)

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.

•   •   •

S
igmund 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 thereby
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.

We had all internalized Lauren’s discomfort and now wanted to push it—and her—away. And therein lies the maladaptive truth of projective identification: It can spark a self-fulfilling prophecy. Fears that infidelity will breach the marital walls
cause
a partner to cheat. Lauren’s fears of rejection, abandonment, and aggression lead to behavior that brings about rejection, abandonment, and aggression. Lauren’s uncle or sister falls ill, she fights with a neighbor, she swallows rusty scissor blades. We prepare to discharge her from the hospital (yet another form of abandonment and rejection in Lauren’s eyes), and she eats chips of wood from the window frame. Soon we all feel angry at Lauren and want her to leave the hospital and never come back.

•   •   •

P
eople who hurt themselves on purpose tend to explain their actions with a shared, if paradoxical, refrain: In situations of extreme stress, self-injury can provide a release. But
how
does this coping mechanism work? How can physical pain relieve psychic pain? How could shedding one’s own blood or purging be comforting? How could swallowing a potentially lethal object make a person feel safer?

To attempt to answer these questions—and therefore to be better able to treat Lauren and other patients like her—I needed to examine both what has happened to self-injurers in their lives to lead them to harm themselves and what happens to them when they do.

It is, of course, impossible to make general statements that apply to an entire population. Nonetheless, psychiatrists and their colleagues have identified that trauma, abuse, and neglect can predispose people to self-harm.

Dr. Bessel van der Kolk, a psychiatrist and preeminent researcher on the effects of trauma, has repeatedly found that the brain can be structurally and chemically altered by severe trauma. If these changes happen at an early-enough age, the resulting damage may be permanent. Similarly, in their 2000 paper entitled “Repetitive Self-Injurious Behavior: A Neuropsychiatric Perspective and Review of Pharmacologic Treatments,” Brown University psychiatrists Rendueles Villalba and Colin Harrington write, “Numerous animal and human studies associate early psychological trauma with subsequent development of repetitive self-injurious behavior.” Villalba and Harrington elaborate on some specific neurological effects of trauma and support van der Kolk’s assertion that the brain is changed: “Overt abuse (especially of a sexual nature), as well as severe neglect, may produce profoundly toxic . . . effects on neuropsychologic development.” They cite nonhuman primate research that found that “early social isolation frequently leads to repetitive self-injurious behavior” and that primates who were deprived of social contact and support not only hurt themselves but also exhibited changes in both the structure and function of their brains.

These findings hark back to a famous set of experiments with rhesus and macaque monkeys, conducted from the 1950s to the 1970s by Margaret and Harry Harlow. In a series of heartrending studies, the Harlows separated infant monkeys from their mothers, sometimes keeping them in isolation chambers for up to two years. The experiments yielded some of the most durable scientific findings on the psychological and behavioral consequences of social isolation in primates and prompted a radical reexamination of the importance of parent-infant bonding. (They also, unsurprisingly, contributed to the rise of the animal-rights movement.)

The isolated Harlow monkeys were subjected to a variety of environments and stressors, and their responses were dutifully recorded and analyzed. Through their experimentation, the Harlows found that baby monkeys who were isolated differed in many ways from their nonisolated counterparts. “Total isolation . . . for at least the first six months of life,” Harry Harlow writes, “consistently produces severe deficits in virtually every aspect of social behavior.” Monkeys who had been isolated “were grossly incompetent” in their social interactions. “As infants and adolescents,” Harlow writes, “they failed to initiate or reciprocate the play and grooming behaviors characteristic of their peers.” As adults these monkeys did not engage in normal sexual behavior. They showed abnormal levels of aggression. And the females who had been isolated subsequently made terrible mothers, ignoring or behaving violently toward their offspring. Monkeys who had been isolated for six months “demonstrated limited social recovery” when reintegrated with a primate community. In monkeys who had spent their entire first year of life in total social isolation, no recovery whatsoever was shown. Harry Harlow’s discussion of this finding is appropriately grim: “The effects of six months of total social isolation were so devastating and debilitating that we had assumed initially that twelve months of isolation would not produce any additional decrement. This assumption proved to be false; twelve months of isolation almost obliterated the animals socially.”