When I came to psychiatry, I was not drawn by the major disorders like Schizophrenia or Manic Depressive Illness. My experience with madness was like most, spotty from encounters in life – a Manic who wandered into a clothing store where I worked, a medical school classmate who had a psychotic break in our first year, things like that. My interest was in the walking wounded, in part because I’d realized that realm was not so personally distant after all. But those first years of residency were spent primarily among the ranks of the very ill. And the realities of those acute wards in the VA, the state facility, and our charity hospital were as disconnected from the uplifting deinstitutionalization and scientific pharmacotherapy rhetoric of our lectures as you could imagine. It was a time like now when in the public dialog, psychiatry was described as the problem, but that was hardly the point on those wards where wheelchairs were as frequently flying missiles as conveyances. It was an unfamiliar terrain where my first patient had drowned two of her children under God’s direction [something I've personally not seen since]. But in those days, I understood early why psychiatrists had been called Alienists.
I’ve wondered over the years, why I never looked back to my first career as an Internist embedded in the comfort of hard science. It felt like I’d moved to a new country, and I hadn’t come for as visit but to stay. I mostly remember night call, when a steady stream of patients were reluctantly brought in because they weren’t handling the world and were making that extremely clear, but rarely seemed to to be glad to be in the emergency room either. So many stories. Once, I made the mistake of sitting by the door interviewing a very agitated and psychotic young man, inadvertently blocking the exit. I found myself held aloft against the wall looking at a cocked fist. I said, "You’re scaring the hell out of me." He said, "You’re not afraid of me!" I hastened assure him that I was very serious about my fear [and I was]. He stopped and said, "You got a straight jacket?" I said, "We don’t have those anymore, but I have some officers who can take us to a safe place." And he walked with me to the locked ward where we talked calmly. So many stories on the way to learning about fear, mine and other’s.
But that’s not the story I started out to tell. I developed something of a hobby on those nights. We saw a lot of patients who were "on the road" traveling on some journey with no clear destination. I began mapping their travels. I remember one guy who had been moving in enlarging circles from his parents’ home in Baltimore. I sketched his forrays on a desk-blotter map as he recounted his travels. I made up a name – Schizophrenia Migrans – the wandering Schizophrenic, and there were many. I speculated that they were looking for a place that "felt right" and I think I was right about that. I spent those early years doing what I do in an unfamiliar place – I read and read. I came to see what we call Schizophrenia as a way of living, hardly alien, just different with different rules, and I considered making it a life work. But as most of us know too well, we were headed for a time of medicalization and that wasn’t where my own wanderings were headed. So after those years, I drifted into the equally fascinating world of neurosis, a word now villified [unless you live there]. But those early years are still emblazoned on my memory and come up frequently.
So to my story. One night, I was lying on the bed in the on-call room. It was off a hallway that lead to the Emergency Room desk. I recall that I was reading a book by Allen Wheelis, a psychoanalyst/writer who had had his own brushes with psychosis and wrote about it eloquently. Earlier, I had admitted a young man to our "overnight" unit in the ER itself. He was such a case of Schizophrenia Migrans who had been picked up on the highway confused and psychotic. On arrival, he’d said, "I need some meds" and told me which one. The "voices" had become ominous. As I was reading later, I became aware of a presence and turned to see him standing in the room near the door. He said something like, "I was wondering. You seem like a nice guy, and I was wondering if you wanted to hear my voices." I don’t recall what I said, but it wasn’t "yes." He said, "I understand. But, you know, when you’re on the road, they can be great comfort – like company, except sometimes they really turn on you." And he went back to bed.
That said, this morning I read Allen Frances’ post, Psychiatry and Recovery: Finding Common Ground And Joining Forces, about a TED talk video. The comments focus on Dr. Frances and his discussion, pro and con about disease models, medications, and the like – arguments we’re all familiar with. I have another hobby – one about dilemmas. I can argue either side with equal facility, sure I will leave no lasting legacy on either side of that coin. Instead, I thought of my stories as an introduction. Here’s the fascinating video: