The human heart has a want that science cannot supply.
—SIR WILLIAM OSLER
When on leave from my psychiatric residency for alternative military service, I spent two years in rural, impoverished northern Maine—in Aroostook County, about eight hours by car north of Boston and near the Canadian border. For a good part of my stay, with only eighteen months of psychiatric training, I was the only psychiatrist in this vast and hurting county.
I had three populations of patients: Anglicans, farmers mostly, some of whom were of Mayflower stock; French Canadians who lived on the US side of the border with Canada and did a fair amount of the forest logging; and a number of Native Americans from tribes living on reservations across the county. (I also treated members of the US Air Force and their families at Loring Air Force Base, now defunct, but that’s another story.)
One day, when rounding at the community hospital where I ran ten inpatient psychiatric beds (sharing the same floor as pediatrics!), a Native family of adults arrived and wanted to see me, likely from either the Mi’kmaqs or the Maliseets, who predominated in the region. The Native Americans kept their distance from the white people, even in medical matters, so it was a surprise for a Native family to show up and ask to see the psychiatrist.
The aide brought four people into an examining room located off the shiny hospital corridor. One man looked in his fifties, while the rest—one woman and two more men—appeared to be in their twenties. One of the younger men was highly agitated, with his eyes darting around the room and full of fear. The others tried to calm him, but it didn’t help much. Only by surrounding him did they keep him from bolting.
I remembered from my training to give an agitated patient plenty of room so he or she wouldn’t feel cornered and slowly approached the group. The older man stepped forward and told me that his nephew Tom had been drinking heavily for months and then stopped a day or two ago. Tom wanted to quit, the man said; Tom wanted to try again at school, to be the first one in their tribe to succeed at college.
At least Tom had been drinking legal beer and spirits and not drinking denatured alcohol or inhaling Sterno (or some other poison) that would quickly destroy his brain—and with which there could be surprises in managing his withdrawal. Athletically built with long, thick, lustrous black hair, Tom was dressed in jeans, work boots, and the kind of parka that residents of the area commonly wore in winter. He looked older than his twenty-three years, and haggard. The uncle said a doctor had told Tom he had a problem with his heart, but otherwise he was “good.”
When I tried to say something to Tom, he glared at me; he was grossly tremulous and sweating profusely. He was clearly in withdrawal; sweating suggests fever or worse. His nervous system was hyperaroused, with norepinephrine and cortisol being released in torrents, driving up his heart rate and blood pressure, raising body temperature and steering blood to the muscles. Under circumstances of serious threat, this is called the fight-or-flight response, evolution’s kind contribution to our survival. But a body system evolved for one purpose can be rerouted, as it is in delirium tremens (DTs), a medical emergency. With the DTs, Tom’s blood pressure and pulse could so elevate that his heart could not sustain its physiological demand; he could go into cardiac collapse and die, especially if he had preexisting heart disease.
I left the exam room, found the nurse on duty, and suggested that we get Tom into a single room away from everyone else. I wrote orders for detox with Librium, the choice at the time, and folic acid to prevent a rare complication of alcoholism called Wernicke’s encephalopathy, in which healthy brain tissue denied this essential nutrient dies. “We need to get his vital signs and a cardiogram,” I told the nurse, adding, “He doesn’t look very well disposed to being touched.”
About five minutes later, the nurse emerged from the exam room and walked slowly toward me. “Hello, Doctor,” she said with her usual practiced formality. She had spoken with Tom’s sister (the third man was his brother), and together they persuaded Tom to let the nurse take his pulse, blood pressure, and temperature. They all turned out to be too high, no surprise given what I saw clinically. But his pulse was strong and regular. In a quiet single room surrounded by his family, he took several high doses of Librium and some fluids and began to settle down. I concluded that Tom had begun the DTs with the horror, disorientation, and nervous system arousal that characterize the condition. But treatment had begun early, and he was responding. His family were never more than a few feet away from him throughout the many hours needed to stabilize him. That meant far more to him than I understood at the time.
I was witnessing a family making a lifesaving treatment possible. To get Tom to stay, at least for the first few days, I agreed that his family, however many they wanted, could share the room with him—and they did, day and night. They were his bridge to reality, his touchstone to trust, as well as protection for hospital staff should he suddenly become paranoid and strike out. The family were critical, as well, in conveying Tom’s life story, not only in their words but also in their actions.
Tom’s sister told me that he had been a handsome and talented adolescent with a quick mind and reflexes, one of those youths who stand out wherever they are. He was the firstborn in his family of four children. His mother died from a car accident when he was ten, leaving him in the care of her brother; Tom’s father had left the family and was seldom on the reservation. The uncle was a leader on the reservation, not too heavy a drinker, and stayed close to home. Tom was a good student on a reservation where education had little value, and he became a pretty good boxer. While he would never be a contender for the Golden Gloves, he was fast and aggressive and knew how to outwit an opponent. Smart, athletic, and attractive, he stood out in a community where alcoholism, aimlessness, and unemployment were the norm among young men. Tom had enrolled in the state university, a ride south of the reservation, which provided him with free tuition and board and offered the promise of a life different from that of his friends and family. Tom was the first one to try. No other member of this reservation had ever gone away for school. That was five years before I met him.
When he quit school for the first time to come home, his family persuaded him to return. He still carried the family’s hopes and pride for his achievement, and he liked the feeling of being first. But one school leave followed another. It was not the studies that got to him. Ironically, what gave him strength was also his undoing: his profound attachment to his family and community, and theirs to him, was essential to his psychic equilibrium and his capacity to succeed. Without them, he was a lost soul. Many youths can take the feeling of secure attachment with them wherever they go, but Tom’s emotional security was dependent on feeling his family’s presence daily and visibly—and college was hundreds of miles away.
Within a few days of arriving at the hospital, Tom was well into a controlled, medical alcohol detoxification. The DTs abated, he was able to eat, hold down food, and sleep, though fitfully. It was weeks before Tom would be ready to leave the hospital, using the time to rebuild his health and regain some of his confidence and hope for the future. I was in no rush to discharge him, and he and his family had more or less set up camp there anyway. As the DTs passed and his acute withdrawal was complete, further evaluation done on his heart revealed evidence of some enlargement. It didn’t need medical treatment, but would heal itself if he stayed away from alcohol and its cardiac toxicity. I came to see the charm and intelligence that had won him so many supporters and opportunities. I began to think he could return to school once again. But he could not and would not. He seemed to know that.
When he was due for discharge from the hospital, I offered to see him as an outpatient in one of my clinics. I had patients throughout the county and rode a circuit regularly from the southern town of Houlton to various French border towns such as Fort Kent and Madawaska. Mostly I saw people in consultation or to prescribe medications, working with psychologists and social workers who provided the ongoing therapy. This type of team care has only become more necessary to meet the needs of people with substance use and mental disorders in this country, especially in rural and underserved communities.
Tom came to see me four or five times as an outpatient in the year that followed. He would make an appointment and then, usually, either not show up or call to cancel. When he came, it was always with family. I tried to understand what he wanted and what stood in his way, a practical version of therapy, but in retrospect I think I had an inadequate understanding of his dilemma. I did not fully appreciate how family and community were his psychological oxygen, and that he could not emotionally breathe without them. I never visited him on the reservation, which I regret. I did not understand that when he did not come to me, I needed to go to him. I did not work with him and his family in a way that recognized that they were one entity, one living organism, which could not bear separation. I had a lot to learn—not that I’m now finished.
Over the year or so I was his doctor, Tom would work some, stay sober, and then start drinking again. When he was drinking, he was most at ease with himself and his community. He was part of them. He was safe. I see that now. He did not have to try to scale the emotional wall of guilt and disloyalty he felt in leaving, no matter how noble or idealized the pursuit seemed to be to his family and friends. Nor did he have to feel the insecure attachment, the separation anxiety that emerged when he was apart from his family and community. By staying and living the life of the reservation, with its intensely intertwined families and the bonding that drinking among the men provided, he could satisfy his needs, every day, even at what would be so great a cost.
Tom was years into and dependent on a mind-numbing and physically addictive substance before he came for care. I wonder what might have been different had his school, his family, and his community been able to foster early on a secure sense of attachment and the inner capacity to stand on his own while still being fully connected to those he loved. His set, or underlying psychic nature or personality, had been shaped by trauma and adversity and was built on dependent, not independent, attachments. Maybe, I thought back then, he could achieve the independence he needed to successfully leave his family (and his addiction) and become his own man. But I know now that his community, his context or setting, was such that drinking was normative and exit to a different life, apart, was improbable.
The last time I saw Tom, he was drinking again. He told me he had begun a medication for his heart, for an arrhythmia, or irregular heartbeat, that he had developed. He said, “The family doctor who came to the reservation said my heart had problems from the drinking. . . . He said my heart muscle had gone kind of soft. I’m going to get sober again. . . . I can do it.”
After my two years of service, in 1974 I left Aroostook County to resume my residency. I had a bad sense about what would befall Tom.
Some years later I revisited northern Maine, at that glorious time in early July when all the potato fields are in blossom, looking like endless white and pink blankets warming the earth as they stretch to the blue horizon. I went to see my friends at the mental health center. They told me about Tom. He had died about a year after I left of a fatal arrhythmia caused by myocarditis, a cardiac complication of alcoholism. One day when drinking, he dropped to the ground, dead, while walking around the reservation.
* * *
Tom’s story comes back to me now as I write this book. He was my first extended and profound immersion into substance use, abuse, and disorder. To set and setting. To secure and insecure attachments. To trauma too, namely for Tom’s losing his mother at age ten.
Back then, there was AA, but not for Native Americans. Back then there was no SBIRT, screening for problem drinking and drug use, especially in adolescents, so that early intervention might be possible. Back then there was no MAT, medication-assisted treatment; he would have been a candidate for long-acting naltrexone (Vivitrol) had it existed. He had the support of his family, but that had its paradoxical side because he could not pursue a life away, a life of his own. There were no relapse prevention groups or CBT to help him regulate his impulses and self-destructive behaviors.
My memory of Tom, his people, a world of unattainable opportunities, leaves me pained and empty. It also reminds me about how much we have learned about more successfully working with people with addictions. And it gives me the drive to keep trying to make a difference in the lives of people with substance use disorders, their families, and their communities.