FOR THE MOST part, we were treating patients with schizophrenia, both the chronic and acute types. This is a major mental disorder, primarily of cognition, with both positive and negative symptoms. The positive symptoms include delusions, hallucinations, and disorganized thinking and speech. The negative symptoms include flat affect, inability to experience pleasure (i.e., anhedonia), lack of motivation, poverty of speech, and problems in forming relationships. These symptoms cause problems with working, memory, attention, and speed of processing. These are termed executive functions (e.g., understanding information and making decisions). These patients seem to lack normal emotional responses, adjust poorly to life changes, and have little insight or self-reflection. Interpersonal and emotional withdrawal are common.
Onset of this disorder typically occurs in the early twenties, but it can occur in children and adolescents as well. It is equally present in men and women. Are they violent? Few are, but don’t tell that to our psychiatric aides and other staff who had to put these patients in restraints with some degree of frequency. In my experience, patients with the paranoid form of schizophrenia tended to have more trouble controlling their emotions, as well as acute patients who tend to become violent at home towards their family members. Modern medications have controlled much of the violence seen in these patients, but the medications in use during the years I worked at the hospital were not as effective. The suicide rate among these patients was also higher than that seen in the general population, as we’ll discuss in a later chapter.
There were other forms of psychotic patients admitted to our hospital. I need not go into these varieties here, but will refer to some of them later as well.
GETTING ADMITTED
Most states mental health laws stipulate the requirements for admission to a state mental hospital: The person must be a danger to himself or herself or a danger to others. Being a danger to himself need not imply suicide. If a patient is unable to care for themselves, that could meet the requirements.
Generally there are three ways to become a patient at such facilities: commitment, voluntary admission, and involuntary admission through petition.
• Commitment is court ordered and hence a judicial process must occur before an involuntary admission is mandated by a judge.
• A person may also sign a petition for hospitalization, which allows the patient to be brought, usually by ambulance or by the police, to a mental hospital for evaluation. This paperwork is available at the hospital upon arrival. Certain designated mental health professionals may complete this petition, which allows the hospital to keep this patient for up to 24 hours, until a physician signs the second petition, which will involuntarily hospitalize the patient for a specified period of time. In most states this interval is generally from three to five days. In our state, the period was five days. If a physician signs the first petition, then the mental hospital may retain the patient for the specified interval and a second petition is not required. One requirement of designated staff at intake, when completing this petition, was the fact that we had to specify what we clinically observed when evaluating the patient. We could not indicate what the family said, because legally that was considered hearsay evidence.
• A patient may also seek voluntary admission to the hospital and the clinical staff, hopefully with the cooperation of the patient and the family, then determines the length of stay.
Because of the paperwork involved and the ease of voluntary admission, most involuntarily admitted patients are encouraged to sign voluntary admission papers after they appear on the ward. If an involuntarily admitted patient refuses to sign voluntary papers, then the hospital must discharge them after the specified holding period, or take them to court seeking commitment. Similarly, if a voluntary patient seeks discharge and the staff feels the patient is not ready to be discharged, then they may sign a petition seeking commitment. Again, after the patient is given notice of his intent to be discharged and after the staff decides not to honor the discharge request, then the patient is notified that he will have to go to court and either be committed or released.
We were fortunate to have the court right at our facility, and I had to testify frequently at these court proceedings. Again, the testimony is to convince the judge that the patient is a danger to himself or to others in order to be retained as a committed mental patient. The patient and the family are notified of the commitment date, and may also testify.
At the beginning of my tenure, I worked as a staff psychologist on an intermediate-care ward that had “acute” admissions as well, and on a unit that housed chronic patients intermingled with acute and intermediate patients. These chronic patients were not expected to be discharged, whereas the acute and intermediate care patients were expected to eventually be released.
Later, the hospital reorganized and developed an acute care unit where the requirements were to discharge the patient within 30 days. If this could not be accomplished, they were to be transferred to one of the many intermediate care wards.
WORKING INTAKE
At one point the hospital decided they wanted more professional experience at that duty station and to relieve some of the pressure on the full-time social workers, who had been assigned to that institutional role. It also came at a time when the doctors were complaining about their role there, feeling there were not making the final decisions about admissions. My real opinion was that this decision to include psychologist to work intake had nothing to do with wanting “more professional experience” and had everything to do with placating the physicians.
I had been on leave studying for my doctorate and was returning to work at the hospital full-time during the summer. The Chief of Psychology assigned me to work intake one half-day a week. I’m sure he saw this as one easy way to fulfill his orders from his boss—the superintendent—and that was one less psychologist who would not get irritated at the assignment. Besides, I really didn’t mind, because I asked to be assigned there during the morning shift. Patients usually didn’t arrive until about two hours after I began my work shift. That allowed me to go to the library, take out books and journals, and work on my literature review for the topic I had selected for my dissertation.
It turned out to be a good assignment and I found I actually liked it, as long as it didn’t last for more than a half-day. There was another benefit for me. I learned who and who did not need to be hospitalized, and I had some interesting experiences there as well.
One that I particularly remember was an acutely paranoid patient brought to the hospital by the police. I do not remember why he had been apprehended, but he was difficult to interview, delusional, wary, glassy-eyed, and quite agitated. I told him he had to be admitted to the hospital for a few days “for observation” (that was a lie hoping it would settle him down), and then he said, very calmly:
Patient: “Ain’t I entitled to one phone call?”
Me: “Yes.”
Patient: Well, I want to make a phone call.”
Me: “Okay.”
I handed him the phone. I assumed he was calling his lawyer or maybe a family member, but no. He called a new car dealer.
Patient: “Hello, let me speak to Mr. ______.” Pause. “Hello, Mr. ______, this is _________. You may recall I recently bought a new car from you on time. Well I’m being railroaded into a mental hospital where I don’t belong so unless you get me out of this, I won’t be able to make the monthly payments. So I want you to get me a lawyer.” He handed me the phone. “He wants to talk to you.”
Me: “Hello. This is Mr. Craig.”
Salesman: “I have just spoken to Mr. __________, and he said he’s being admitted to the mental hospital. He wants us to get him a lawyer. What do you say?”
Me: “He doesn’t need a lawyer. We have public defenders here and, if he doesn’t agree to the admission, he will be admitted on an involuntary basis, and then, within five days, he will go to court and will be provided a lawyer at the state’s expense, so you don’t have to get him one. Were you actually going to get him a lawyer?”
Salesman: “Well, we do have a lawyer here and I was going to look into this for him, but since you say you will provide that for him, I needn’t bother. Thanks.”
I was somewhat flabbergasted to think that a car dealer might provide a lawyer for a private matter.
YOUR DEFLECTION RATE IS TOO LOW
Somewhat later, I had graduated and was working as a staff psychologist and had been assigned as head of the acute admissions ward. My supervisor, then in his late 50s, had left and gone to law school. He subsequently graduated and specialized in mental health law. I was assigned a new female psychologist as my immediate supervisor. She was a very competent administrator and most of us saw her climbing the ladder in her career ambitions, which she later did.
During this period of time the hospital made a policy decision to “get rid of” as many patients as they could. “Spin them off to the community” was the way they put it, and I was partially assigned to work with community groups to try to get them grants so these patients could be treated there instead of at our hospital. That wasn’t easy, as you might guess and I found myself moving further and further away from my primary interests, which was to treat psychologically disturbed patients.
One day, she called me into her office and informed me that she was assigning me to work intake one half-day a week. I would work there Tuesday morning and, since I would go to the community-based outpatient clinic on Tuesday afternoons, she thought she was doing me a favor by not having me work on my unit for one full day a week. Actually I loved working on my unit, felt responsible for what was happening there and didn’t like to be away from there for so long (except when I was on vacation). Also, I didn’t want to work intake. That didn’t matter. That was where I was assigned and that was where I would work. I told her I would do my best—and I think I tried to.
Then one day, she called me into her office again: “Bob, your deflection rate is too low.” By that she meant I was admitting too many patients.
“June, if you think my deflection rate is too low, then assign someone else there that will give you the deflection rate you want. But if you assign me there, I will use my professional judgment and I am going to admit patients that need to be admitted.”
She did. I was taken off intake. I guess both she and I were happy. She was in a bind. She needed to reduce the number of patients being admitted to her section of the hospital, because that was the hospital’s goal. I understood that, but I didn’t like the fact that patients were being denied admission that I felt needed to be admitted. I also own up to the fact that sometimes I would admit a patient who didn’t have to be admitted, to give their caretakers a rest. But that didn’t occur all that frequently and didn’t account much for my “deflection ratio.”
OPEN HOUSE
The hospital had reorganized itself into regions. In our area, we had three units responsible for two regions of the city. I was eventually selected as the director of the acute admissions unit that received patients who were living in one of the most impoverished, crime-ridden, and minority-laced wards of the city. The other unit received patients from an all-white area of the city. Patients in these areas were educated, employed, and had positive family support. Both these units transferred patients to our intermediate care unit if they could not be discharged within a reasonable amount of time. The non-minority unit didn’t seem to have time requirements for their patients, but my unit was required to discharge them within thirty days or transfer them to the intermediate care unit.
Our regional supervisor decided to hold an open house for family and community members, and the non-minority unit was selected to be the unit that would be open for review. My boss asked me to be present and greet the public, even though I was not assigned there and didn’t know any of the patients. A foreign-trained female psychiatrist headed the unit and her English wasn’t particularly good, though we got used to it and could mostly understand her.
On the evening of the open house, I was escorting some family and community members around the unit and we went into the recreation room. Below the sink and counter tops were cabinetry, so one of the visitors asked what was in the cabinets. I told her I wasn’t sure, as this was not my unit, but my guess was that it was art supplies, games, and other supplies, since that was what we kept there in my unit. She asked me to open up the cabinet, which I did, and there, inside the cabinet, was a patient.
Me: “Are you all right?”
Patient: “Yeah.”
Me: “What were you doing in there?”
Patient: “Nothing. I was sleeping.”
Community Member: “Do you feel safe here?”
Patient: “Yes.”
Then the patient walked out of the room.
The community group spent the next five or ten minutes asking about patient safety, how we address sex in the unit, issues related to theft, and the like. Later that evening I took the patient aside and asked him again why was he in the cabinet. He said he was hiding, because he lived in the community and didn’t want anyone from the community to know he was a patient there.
HYDRO
We had a special ward for violent patients, and fortunately, I wasn’t assigned to work there. The unit was called “hydro.” That was short for “hydrotherapy.” This was a special intervention type that had been used in the past to calm down patients. It was basically a hot sitz bath. The patient was immersed in hot—but not too hot—water. A tarp-like covering was placed over the tub and anchored with ties into the tub, securing it in place, while the patient’s head protruded out of the tub, to allow ease of breathing. Before the invention of tranquilizers, hydrotherapy was in common use in psychiatric hospitals. By the time I came along, the bathtubs were still on the ward, but no longer used. But the place was still called “hydro.” When a patient was sent to “hydro,” interventions consisted mostly of heavy doses of tranquilizers, i.e., chemical restraints, as well as physical restraints. So it was not a pleasant place to be for staff. Once patients returned to their usual emotional state, they were transferred back to their previous ward.
AUTISTIC?
One day we received a new patient when I was working on the intermediate care ward. He was a 25-year-old white male, with a diagnosis of autism and schizophrenia. I’m unsure if that diagnosis was correct, but what I do know is that the patient didn’t talk. He was put on heavy doses of tranquilizers and his treatment consisted of “milieu” therapy.
I tried to engage him therapeutically with individual sessions, but it was hopeless because he seemed uncommunicative. However, I learned that he liked to play chess, so I met with him every day and played chess with him. I would make comments to him during the game, which required him to listen but not respond. These comments included such things as “Boy, that was a good move.” Or when it appeared he was getting the upper hand, I might say “I think I just goofed.” Sometimes it was just a simple thing, such as “It looks like a nice day today.”
Now when I used the phrase “he was getting the upper hand,” that was pretty easy to do, because I was not a good chess player, nor was I interested in the game. I just wanted to engage him and see what information I could glean from him. I began asking him more personal questions, such as “How old are you?” “Are you married?” Where were you born?” I never asked more than one personal question during any one game. He actually began giving me one-word answers and, over time, we did get some history on this patient.
There was a day, however, when I was beating him and I think I actually would have checkmated him. However, he “accidentally” bumped into the table, knocking the chess pieces on the floor. “Oh!,” I said. “That’s too bad.” That never happened again because I never again was in a position to win.
I included him in my therapy group on the ward, which was held three times a week. Under normal circumstances, group therapy was not the treatment of choice for such a patient, but I wanted him to get some social interaction, so I insisted he attend. Of course, he never said a word.
I would walk around the ward, corralling the patients and leading them to our group therapy room. I would make an announcement over the PA system we had, but they rarely came voluntarily so I just went around collecting them. One day this patient wasn’t in the usual places, so I went into the bed area, and sure enough, he was in bed. It was well past breakfast and so I asked him to get up. He never budged. I told him again to get up, because it was time for group therapy. Again he didn’t move. So I got closer to the bed, gently touched him on the shoulder and told him to get up, this time more affirmatively. He jumped up and began swinging his arms wildly at me, trying to hit me. I kept backing away calmly, telling him to “stop it.” He never really came close to landing a blow. Then he said, “Oh, I must have been dreaming.”
Now that was the most we ever heard from this patient since he was admitted to our ward. The next morning, at our regular team meeting, I reported this incident to the staff. The doctor laughed and snickered. Later that day, he wanted to see the patient for a medication review, but the patient didn’t show up when called over the PA, despite several attempts to page him. So the doctor went into the dorm, and sure enough, the patient was in bed. When the doctor tried to rouse him, the patient came up swinging, and he did land a few light blows on him, but the doctor was basically unhurt. Later that afternoon, the doctor transferred him to hydro. He was then transferred from there to one of our chronic care units for essentially custodial care.
ANOTHER MARRIAGE
We had a patient in her late 20s, a white female. She was quite sexually active but “unable” to have coitus. She willingly engaged in oral, anal, and manual sexual relations but had a hangup about the usual type. That wasn’t the reason for her admission to a mental hospital but it was the issue we focused on with her in therapy. We tried to find the basis of her fear, if that was what it was, but didn’t make much headway.
Many months later, she and her boyfriend came to see me, asking for a letter stating that she could engage in normal sexual relations. They were planning to get married in the Catholic Church, and a background check revealed she had been a patient in a mental hospital, so the priest wanted an expert stating her sanity was intact and therefore she could validly enter into a Catholic marriage, according to cannon law. But if she was unable to have coitus, then that would be grounds for a later annulment and I wanted to prevent some later troubles by ascertaining whether or not she could engage in normal relations. If she was unable to do that, then I would have reported that to the priest, as she had signed a letter allowing me to report my findings to him.
I interviewed her at length and found her sane, recovered, and functioning well without medication. However, if she was unable to have coitus, then I didn’t think she couldn’t validly enter into a Catholic marriage, and I wasn’t sure that she had told her priest about this aspect of her problem. So I investigated this area of her life in the interview and, sure enough, she hadn’t confided that problem to him. Upon inquiry, she alleged that issue was behind her and she had her boyfriend were having normal relations.
However, I needed to confirm this, so I interviewed her boyfriend alone. I asked him if he was aware of her prior sexual difficulties. I didn’t want to be specific, so as to not violate confidentiality, and he said he had. I asked him to be specific about what exactly were those prior difficulties and he accurately identified them. He confirmed to me they had been sexually active, including coitus, and were not having any sexual problems. So I provided them with a letter of attestation, affirming her recovery from mental illness, which they knew about, and phrased my letter delicately stating that she and her fiancé report she has overcome other difficulties that could have affected her ability to marry within the Church. Since I had no way of assuring that, I had to go on the basis of mutual self-report.
GAS STATION GUS
One morning I was driving to work and stopped at a gas station to fill up, when I saw one of our patients walking down the street in his pajamas and hospital-provided robe. He was a good five miles from the hospital, so I walked over.
Me: “Where are you going?”
Patient: “To the airport.”
Me: “Why?”
Patient: “I’m going to see my brother.”
Me: “Where does he live?”
Patient: “In St. Louis.”
Me: “Well, you’re going the wrong way. The airport is in the other direction. Get in my car.”
I drove him back to the hospital and escorted him up to our fourth-floor ward, where the patients were still eating breakfast. I reported the incident to our unit psychiatrist during the morning report, and he just laughed.
WRIGLEY FIELD OUTING
Schizophrenia is primarily a thought disorder as opposed to an affective disorder (e.g., depression). Sometimes, patients manifest features of both a thought and an affective disorder. Then they are diagnosed with a schizoaffective disorder.
As mentioned earlier, theoretically there are two types of thought disorders: (1) concrete thinking, and (2) overinclusive thinking. In my experience the overinclusive type is far more common in practice, but occasionally we did see patients with the concrete type. The following two episodes exemplify this.
For some reason, psychology departments are located in the basement of buildings. I don’t know why we could not occupy the penthouse, but we tend to be housed at the lower levels. Finally the hospital reorganized and we were relocated to the fourth floor of a newer building. I had the lowest seniority among the staff, so I was assigned the job of coordinating the move. Staff labeled each of the boxes with their name and designated room assignments. Among my duties included the responsibility of telling patients where to place the boxes as they brought them into the new location
Now patients “volunteered” to carry these boxes. They called this “vocational therapy,” but the patients had little choice. They simply were told what to do and they did it. The selected patients were probably chosen for their obedience, compliance, and strength. Later, court rulings decided that this patient labor violated work rules and they had to be paid at least a minimum wage. At our facility this essentially eliminated our free labor force. But at the time this ruling had not yet happened and the patients were carrying the boxes into the new building.
As each patient came in, I inspected each box and told the patient where to place it. I was already in one of the rooms when a patient came in holding a box. I checked the room assignment, which was where I was already, so I told the patient, “Just drop it here.” And he did. He dropped it right where he was standing! Was that an example of concrete thinking or an example of retaliation for doing something he really didn’t want to do? From then on, I gave specific location instructions as to where to place the boxes (e.g., “place it in the corner”).
Sometimes patients were allowed to go on “field trips,” provided they were in good enough shape for it. During one such event, our ward was selected to attend a baseball game at Wrigley Field. Now, as a lifelong Chicago Cubs fan, I eagerly volunteered to escort the patients to the game. These days you have to buy your tickets well in advance and the stadium is usually sold out. But years ago, you could get good tickets to most any game just by going to the ticket window on game day. So another staff member and I went with a small group of patients to the game, which, fortunately, was sparsely attended.
We were seated along the far left field side of the stadium, above box seats and somewhat back of the area that is now unfortunately called the “Bartman seats.” One of the male patients asked me if he could go to the bathroom. I knew this patient and knew he could go unescorted and find his way back with little concern on my part, so I assented. After that, he stood up, unzipped his pants and urinated on the concrete steps as the surrounding patrons looked aghast. This gives yet another meaning to the term “concrete thinking.”
REORGANIZATION AND DIAGNOSIS
Psychiatry has evolved and differentiated from its rudimentary beginnings, emanating from the seminal writings of Sigmund Freud, to today’s emphasis on biology and neuronal organization. Even before Freud, actually, there was a psychiatric history.
In the late 1800s, only a few diagnoses that fell within the purview of psychiatry. Those included monomania (i.e., depression), dipsomania (i.e., alcoholism), epilepsy, idiocy (i.e., mental retardation), and paresis (i.e., syphilis of the brain). In the early 1900s, Emile Kraepelin, considered the father of psychiatric diagnoses, began to systematize psychiatric diagnoses. His work culminated in the first official diagnostic nomenclature, the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM), now in its fifth iteration and several inches thick. What we are now calling schizophrenia he once called dementia praecox.
Coinciding with the development of psychiatric diagnoses was the evolution of care of the mentally ill. In the 1800s, a French Physician, Philippe Pinel, received an appointment as head of the asylum at Bicetre and Salpetriere. At that point in time, the mentally ill were kept in chains. Pinel removed these shackles and instituted more humane treatment. During the American Civil War and after, Dorothea Dix campaigned for more humane treatment of the mentally ill, as well as arguing for better facilities to care for them.
In the first half of the 20th century, mental hospitals in American were largely custodial institutions for the chronically mentally ill. There were acute admissions, but these were housed separately from the chronic patients. The treatment that permeated these places essentially included medication, milieu therapy, and custodial care. Just a few decades earlier, psychiatry was using insulin shock therapy (intentionally reducing blood glucose levels, thereby producing a seizure), electric shock therapy (putting electrodes at various point on the scalp, sending an electric current to the brain, resulting in convulsions), and lobotomy (severing the frontal lobes of the brain). During my tenure at the hospital, I did see a few residual cases that had had these surgical procedures (they appeared “dehumanized”), but these interventions had become passé by the time I arrived on the scene.
Someone at our institution got the ridiculous idea that chronic mental patients would improve their cognition if they were mixed in with the acute patients. So overnight, our 50-bed intermediate care ward became a 100-bed ward (with no designation). Not only that, but we went from an all-female ward to a mixed-gender ward. An unused wing of the building was available to serve as sleeping quarters, but patients were to be mixed in all other ways. That meant in recreation on the ward (that was [sort of] okay), meals (that was okay but did present problems), and “treatment.” I never understood what the latter meant, since these patients were not amenable to psychotherapy of any form and were given medication, but individually dosed, like all patients.
Anyway, our unit psychiatrist felt obligated to conduct a “psychiatric interview” with these new patients, as he was now responsible for their care. He asked me to sit in with him as he conducted the interviews. They typically went like this:
50ish white female
Doctor: “What’s your name?”
Patient: Mumble, mumble
Word salad is a psychiatric symptom whereby the patient speaks using nonsense words, or mixes up words so they make little or no sense. When the patient began to mumble, she was evincing word salad.
Doctor: “How old are you?”
Patient: Mumble, mumble
Doctor: “Do you know where you are?”
Patient: Mumble, mumble
Doctor: “Praecox! Bring in the next patient.” While schizophrenia was then the official diagnosis of such patients, this doctor was still using the old designation of dementia praecox. He just shortened the term. The next patient, a 50ish white male, came in.
Doctor: “What’s your name?”
Patient: Mumble, mumble
Doctor: “How old are you?”
Patient: Mumble, mumble
Doctor: “Do you know where you are?”
Patient: Mumble, mumble
Doctor: “Praecox. Bring in the next patient.”
A 60ish black female came in.
Doctor: “What’s your name?”
Patient: Whispering inaudible sounds.
Doctor: “How old are you?”
Patient: Whispering inaudible sounds.
Doctor: “Say yes or no, did you have breakfast today?”
Patient: Whispering inaudible sounds.
Doctor: “Praecox. Bring in the next patient.”
And so on did it go. I could go on, but to do so, I would have to present 47 similar patients, all with signs of chronic schizophrenia, and all diagnosed by our psychiatrist as “Praecox.”
Now that the patients were on our ward, it definitely changed the ward’s character and dynamic. While they were included in our community meetings, that was a useless exercise, as we spent much of the meeting time trying to control their behavior.
One of the changes was observing the kinds of patients that we rarely see anymore. Newer psychiatric medications have eliminated word salad and catatonic schizophrenia as symptoms and we just don’t see them anymore.
Catatonic schizophrenia is characterized by muscular rigidity in the extreme. The patient remained in a particular position, usually sitting or standing, often in a grotesque posture, and remained that way for days at a time, unable to speak. I did see a few patients with catatonic schizophrenia, but that diagnosis is no longer extant in the official nomenclature (DSM).
HEBEPHRENIA
Another disorder that is no longer extant was called hebephrenia. This was a type of schizophrenia where the patient continuously laughs. We did have a few such cases on our ward. I remember one in particular. He was not a patient on our ward but would stand outside the staff cafeteria, laughing and asking for a dime, while standing next to a vending machine. Whenever he got enough money he would put it into the slot, pull the lever, get a candy bar, and go away laughing. He would return shortly and I assumed he had eaten the candy bar and was back for more. Then I learned that the ward staff searched his locker and found a duffle bag filled with melted chocolate. He never ate them at all and was hoarding them, for some strange reason.
CINDERELLA
Here is an example of the kinds of patients that were forced upon us. She was a 30-40-year-old white female, who dressed as and called herself “Cinderella.” When she got to our ward she seemed to gravitate towards me and would continually come up to me during free times and say “My name is Cinderella. Can I talk with you?” I would respond with “Your name is Elaine.” And she would retort, “My name is Cinderella, can I talk with you?”
This went on for weeks until I told her that if she would come up to me and say “My name is Elaine, Can I talk with you,” then I would talk with her. Otherwise, I would not. Well, one day, it happened. She came up to me and said
Patient: “My name is Cinderella, Can I talk to you?”
Me: “You name is Elaine.”
Patient: “My name is Elaine. Can I talk with you?”
So we went into one of our private therapy rooms, sat down and I asked her what she would like to talk about.
“My name is Cinderella.”
That’s all she would say. I could never get anything else from her but that. Since she was able to say that her name was Elaine, I knew she had the capacity to say more, however, subsequent efforts proved fruitless, and she was classified as a custodial care patient.
IS JOEY HERE TODAY?
During my internship, the Director of Internship Training was off on Tuesdays. He was assigned to one of the intermediate care wards that had received chronic patients overnight. He began working with an elderly white male. Our intern supervisor—let’s call him Joey—was off every Tuesday. And every Tuesday, this chronic patient would come down to the psychology department, (it was in the basement) and ask for Joey. And every Tuesday the program secretary would tell the patient that Mr. X was not here today. And then he would ask “where is Joey?” And the secretary would respond “Mr. X does not work on Tuesdays. And the patient would say “Where is Joey?” And the secretary, trying to hold her patience, would say, “Mr. X is not here today.” And so on it went every Tuesday.
Patient: “Is Joey here today?”
Secretary: “Mr. X is not here today.”
Patient: “Where is Joey?”
Secretary: “Mr. X does not work on Tuesdays.”
Patient: “Where is Joey?”
Secretary: “Mr. X does not work on Tuesdays.”
Patient: “Is Joey here today.”
Secretary: “Mr. X does not work on Tuesdays.”
This went on until the patient became tired of asking for Joey and then left.
Now there was one other feature about this patient that was of interest. He stuttered. He merely didn’t ask “Where’s Joey?” he said, if I can convey this correctly, “Where’s J-J-J-Jo-Jo-Jo-Jo-Joey?” “Where’s J-J-J-Jo-Jo-Jo-Jo-Joey?” “Where’s J-J-J-Jo-Jo-Jo-Jo-Joey?” “Where’s J-J-J-Jo-Jo-Jo-Jo-Joey?” And he would repeat this stuttering phrase until the secretary would interrupt him by saying that Joey wasn’t there that day and then he would go into his next reverberation. “Is J-J-J-Jo-Jo-Jo-Jo-Joey here today? Is J-J-J-Jo-Jo-Jo-Jo-Joey here today? Where’s J-J-J-Jo-Jo-Jo-Jo-Joey?”
Now there was another chronic patient who was assigned janitorial duties in the building that housed the psychology department. He was also an elderly male and did patient labor before the ruling came down that patients had to be paid to provide these services.
His difficulty was another kind of reverberation. We quickly learned to never ask him “How are you.” Instead we simply said “good morning” or “good afternoon,” because whenever anyone asked “how are you?” he immediately said, “I never complain,” but then went into a long tirade about how badly his mother had treated him. If someone would ever stay around long enough to listen to his whole speech, it went on for perhaps 5-10 minutes.
One day, I was coming down the stairs after conducting group therapy with my supervisor, when these two men met in the hallway. The one patient made the mistake of asking the other, “How are you?” Unfortunately his stuttering got in the way of the other patient continuing his complaints after saying “I never complain.” They became locked in an unending “conversation” that went like this:
“H-h-h-ho-ho-ho-how are you?”
“I never complain.”
“H-h-h-ho-ho-ho-how are you?”
“I never complain.”
“H-h-h-ho-ho-ho-how are you?”
“I never complain.”
“H-h-h-ho-ho-ho-how are you?”
“I never complain.”
“H-h-h-ho-ho-ho-how are you?”
“I never complain.”
“H-h-h-ho-ho-ho-how are you?”
“I never complain.”
“H-h-h-ho-ho-ho-how are you?”
“I never complain.”
“H-h-h-ho-ho-ho-how are you?”
“I never complain.”
Well, by now you get the idea. I stood there watching and listening to this interchange that lasted a full five minutes. They were locked in a seeming never-ending reverberation. Finally the “never complainer” said “never mind” and walked away.
FALSE PREGNANCY
The hospital was pressuring clinical staff to discharge patents as soon as possible and to place patients in community-based halfway houses. It was my opinion that patients received better care in our hospital, but at the same time, we were happy to be able to place some of our more chronic patients. However, a few of these patients committed suicide at these facilities and I felt this would not have occurred had they remained with us. Many returned to us, unable to make the transition. One of these chronically mentally ill patients was a 50ish woman who we placed in a halfway house, but she returned to us many months later with a story that her father had raped her at the facility. Her abdomen was fully extended and she appeared to be ready for delivery at any day. Our physician examined her, and told her she was not pregnant. It was a case of pseudocyesis, false pregnancy. After she heard the news, her abdomen returned to normal size within a week and we returned her to the halfway house. An analyst would probably want to probe that whole scenario with her, but we didn’t have the luxury.
GIVE ME THE BUTTS
Another example was seen in a 50-60-year-old white male, who would only say “Give me the butts.” What he was asking for were the remains of a cigarette that someone else was smoking. However, should one of the patients actually give him a cigarette butt, he would throw it out, and then go to someone else saying “give me the butts.”
This behavior irritated everyone, including staff. Occasionally our unit psychiatrist would become frustrated, yell at him, and tell him to shut up. The patients often complained to us about this patient’s irritating behavior, to no avail. Was this yet another symptom, or something else?
I reasoned that, since the patient never smoked the cigarette butt, he must want something else. What could it be? The only other thing I could come up with was he either wanted personal human interaction or he wanted to see our irritation when he asked the “give me the butt” response. I tried to use my training in behavior therapy to address this behavior.
I addressed the problem in a staff meeting, and suggested that we try an experiment to extinguish this behavior. Using a learning theory orientation to my planned intervention, we know that a stimulus followed by a reward will reinforce the appearance of that response the next time this stimulus is presented. However, if the behavior is not followed by a reward, then that behavior should be extinguished.
Let me give the reader a really simple example. Suppose you are walking down the sidewalk and notice something shiny in the grass. You walk over, bend down and see that it is a quarter (stimulus) and you put it in your pocket, to be spent later (the reward). Now what do you do next? I think most people would look around and see if there is any more money lying around the area. If there is, you pick it up (response) and put it in your pocket for later use (as a reward). If there isn’t, you walk away. Your “looking around response” was unrewarded (since there is no more money for you to amass) and this response has become extinguished. The money you now have is called a secondary reinforcement (a primary reinforcer is one that reduces primary drives, such as food and drink), and you will use it to buy something that will then become the reward.
There is also something called “schedules of reinforcement.” Continuous reinforcement (e.g., get the same reward every time you elicit the same response) is the weakest schedule with which to shape a behavior. We simply get tired of “the same old thing.” Episodic reinforcement is the best way to shape a habit. This means a reward is given periodically, but not every time the response appears. This is the principle behind training an animal and casino slot machines: we periodically win when we pull the level or punch the button, but the machine is set up so that most of us lose most of the time.
With this principle in mind, I suggested that we give this patient a cigarette butt according to a schedule of reinforcement that I would develop. I needed a supply of cigarettes, which would last for one month. Each cigarette would be cut into thirds, and staff would give the patient these “butts” at prearranged times. I was excited to try this and see if it would extinguish his irritating behavior.
We asked around for volunteers to give us cigarettes and began collecting the reward we would use in the treatment. They were given to our recreational therapist for “safekeeping.” She was to advise me when she had the necessary supply to begin the process.
Now I bet the reader is now anticipating the results of this experiment. Some of you may think that I would not report such a lengthy explanation of the results if they were not successful, and hence you probably anticipate a positive outcome. Skeptics who have a negative attitude towards behavior modification may expect this experiment to fail.
Well, both positions are wrong. The experiment was never started because someone stole the cigarettes before they could be cut into pieces. I had no faith that we would ever retain enough cigarettes to conduct this intervention, so it ended in an inglorious fashion.
This patient had one other irritating behavior. When he wasn’t saying “give the butts” he was saying “I want to go home.” Over and over again, he said “I want to go home.” Just like “give me the butts,” this was irritating all of us. Then, one day...
Patient: “I want go home.”
Nurse: “Okay, you can go home.”
Patient: “What?”
Nurse: “You can go home. Get your coat and go home.”
Patient: “I’ll go to bed.”
This demonstrates that there was some other motivation behind his utterances, though we never determined what they were.
DONATED DRESSES
Chronic patients on our ward were indigent and relied on social services to care for their many needs, including clothes. My wife was going through her closet and discarding those that she was no longer able to wear. Normally we donated them to veteran’s groups, but I decided to bring them to the hospital and make them available to the female patients on the ward. I thought I would feel a little funny seeing these women in my wife’s former clothes, but I didn’t. I felt good that needy people could get good use from them.
CRIMINALLY INSANE
The Department of Mental Health eventually set up a specialized unit at one of the area’s mental hospitals. Their task was to treat the criminally insane and prepare patients to return to court for judgment. First I want to give the reader a bit of background.
Forensic psychology is the application of psychological methods, theories, and concepts to areas of interest to the legal system. Insanity is a legal concept, not a psychiatric one. However, psychiatrists and psychologists have been called as expert witness for the triers of fact (e.g., judge, jury) to render a decision on a perpetrator’s culpability.
Jurisprudence requires criminal intent (mens rea) to commit a criminal act, which includes knowledge and purpose. The various insanity pleas argue that if one or both of these conditions are not present within the defendant, s/he is not culpable for the offence.
There are a variety of insanity pleas depending on State law. The oldest insanity plea is the M’Naghten rule. This states that a person is insane if he is “laboring under such a defect of reason, from disease of the mind, as not to know the nature and quality of the act he was doing; or, if he did know it, that he did not know he was doing was wrong.”
The Durham Rule says that “an accused is not criminally responsible if his unlawful act was the product of mental disease or mental defect.” The problem with this defense plea is that psychodynamic theory can argue that virtually anything can cause anything else.
A third insanity plea, and one that has gained popularity in mental health law, was developed by the American Law Institute (ALI) and argues that a defendant is not criminally responsible for a criminal act “if the act was the result of a mental disease or defect that caused the person to lack the substantial capacity to understand what one is doing, or an inability to control their behavior.”
A subsidiary plea is called “irresistible impulse.” Here it is argued that, although the defendant knew the act was wrong (a cognitive standard), he was unable to control his behavior. But what is the difference between an irresistible impulse and an unresisted impulse? That is difficult to assess. The courts have subsequently ruled that an impulse is irresistible if the presence of a policeman would not be sufficient to stop the behavior. Thus an exhibitionist cannot use the plea of irresistible impulse because an exhibitionist would be unlikely to expose himself if a policeman was present.
The final plea is the Not Guilty by Reason of Insanity (NGRI), which was developed after Mr. Hinkley attempted to assassinate President Reagan. This judgment is controversial because it says the defendant is guilty but essentially goes “unpunished” and is sent to a psychiatric hospital for treatment. Final disposition is left to the Department of Mental Health and not to the Justice Department.
Guilty But Mentally Ill is a verdict whereby a defendant is committed to a psychiatric hospital for treatment until their mental illness is in remission (or controlled). They are then transferred to a correctional facility to complete their sentence with time spent in the hospital is credit towards their sentence. Many argue that this obviates the issue of mens rea. One result of this verdict is a later Supreme Court rule staying that it is constitutional to involuntarily confine someone who has been acquitted of a crime and used the insanity plea.
Other insanity pleas have been attempted. Duress argues that the defendant was threatened with death or serious bodily harm unless they engage in criminal behavior. Extreme mental or emotional disturbance argues that extreme provocation caused the criminal behavior. Involuntary intoxication can be used as a plea in many states, if they can also show that the intoxication was the result of a mental disease or abnormality. Provocation argues that the criminal act was the result of extreme provocation and was so compelling that any reasonable person would act in a similar manner. The “Twinkie” defense was allowed by the California Supreme Court, arguing that the criminal act was mitigated by eating an excessive amount of Twinkies and that the high sugar content caused the behavior. (The California legislature later repealed this as a defense.) The XYY Chromosome insanity defense argued there was an extra Y chromosome in a male defendant that produced abnormal aggression with poor impulse control. These latter insanity pleas usually invoke one of the other insanity pleas listed above.
With the creation of the forensic unit at the local state hospital, we no longer received such patients, but early in my career we did receive them occasionally. One that I remember quite well was a white male who had been charged with murder. He was deemed unfit to stand trial and sent to a mental hospital. Following a lengthy treatment episode, involving years at the mental hospital, he was considered ready to stand trial and was sent to us pending a court date, after which he would be returned to the court for trial. He had told a “friend” to do something, the man had refused, and the patient shot and killed him. While in prison, he was on the second floor, asked an inmate for a cigarette, the inmate refused, and the patient pushed him over the wall, slightly but not fatally injuring him.
When he came to our intermediate care ward, I had him in group therapy. The goals were to maintain his sanity, prepare him for trial, and assess his sanity and impulse control. As part of the latter process, I gave him some psychological tests. One of the tests administered was the Thematic Apperception Test, a series of pictures, about each of which the testee is asked to tell a story. They should include in their story what was going on in the picture, what led up to it, the thoughts and feelings of the people (if any) in the picture, and how the story would end. They are to do this for each of the 15-20 pictures given. As the patient relates the story, the examiner writes down the story verbatim. The stories are then analyzed along certain dimensions.
One of this patient’s stories was memorable, given the reasons for the assessment. The picture displayed two adults in a room, one male and one female. The woman is lying naked on her back on a bed. The man is standing, fully clothed, with his back turned away from the bed and his arm covering his eyes. This was the story this psychopath told about that picture:
“He was f-----g this girl and she farted. So he stopped f-----g her. If that was me, I wouldn’t care. I would just keep f-----g her.”
Now there were a couple of interesting items to the story that reveals his personality. First, he didn’t follow the instructions. He described what was going on in the picture didn’t include what occurred prior to the scene and omitted the outcome. Second, he omitted reporting on the feelings of both people. Third, in the story he was more concerned with self-gratification than with anything else. Thus we see many of the hallmarks of the psychopathic personality: selfishness, problems with impulse control, and disregard for the feelings of others.
One of the disconcerting issues for us at that time was a ruling by the courts that the defendant could not be returned to court for trial, following a mitigation of psychosis, if that mitigation was maintained by medication. In other words, the patient had to be free from psychosis to be tried. Our difficulty was that we could give a patient medication, which eventually controlled the psychotic symptoms. Thus he could meet the competency standards: he understood right from wrong and was able to cooperate with counsel. However, once the medication was discontinued, the psychosis returned. Then he would not have been able to meet the competency standard. This was often a catch-22 for us, until the court reversed their decision and allowed the patient be tried under medication.
JACQUES
Jacques had an unusual symptom whenever he got admitted to our hospital. He would follow and then scream obscenities at a woman, following her and appearing very threatening and frightening to her. Jacques would never hurt her or even touch her, but the person being threatened would never know that. One day, when Jacques went crazy, he harassed the wrong woman.
During his last admission, Jacques was improving and had a job, which was held for him while he was hospitalized. We wanted Jacques to stay longer, but he wanted to leave. Since he had been hospitalized several times, he was aware of the discharge procedures as well as possible court appearances, though he had never been committed. Jacques continued to press his desire to leave but never signed papers requesting discharge, which would have required us to decide to release him or commit him. As best as I can recall, I didn’t think his clinical condition at the time would support commitment. We continued to encourage continued hospitalization. Jacques wanted to return to his job. So he escaped from our locked ward—more about that later.
Now my relationship with him was good. And a few days later, Jacques called me to report how he was doing. He told me where he was now living (change of address) and where he was working. He alleged he was doing well. I asked him to continue to call me to report his progress and I decided not to officially discharge him for a while and just keep him on the rolls. Should he return, this would avoid a myriad of paperwork.
I told you that eventually Jacques harassed the wrong woman. That woman was a well-known newspaper advice columnist. Jacques followed her, yelling and screaming his usual obscenities, and she called the police. (He later told me he did not know that the woman was a celebrity.) Jacques ran away, but somehow she knew he was a former patient at our facility—I never learned how. Anyway, she called her publisher, who called the Governor, who called the State Director of Mental Health, who called the hospital superintendent, who called me at home:
Superintendent: “Hello, Bob, This is Doctor T…… How are you?”
He never called me Bob! What was all this friendliness about?
Me: “Fine.”
Superintendent: “Do you know a patient by the name of Jacques?”
Me: “Yes, I do.”
Superintendent: “Do you know his address?”
Me: “Yes, I do. I know where he lives and where he works, why?”
He told me. The police later apprehended Jacques at work Jacques and returned him to our hospital. We then received a memo from the superintendent that we were not allowed to discharge him without the approval of the superintendent.
That seemed okay with us, until we tried to discharge Jacques. Dr. T refused to concur with our recommendation. Twice we tried and twice we were denied. We didn’t want to try a third time. Jacques was, in fact, a kind of political prisoner. Now what?
I thought about this for a while. We were an acute care unit but Jacques was on our unit for months and we were not allowed to transfer him to one of our intermediate wards. I decided to take some action.
I contacted DePaul University Law School Dean, and inquired if he would consider law school students coming to my ward once a month and address any of the legal issues with which any of our patients may need assistance. It took several weeks but we were eventually able to have two students, under supervision, come to the unit for a few hours. The first patient we provided access to was Jacques. We explained the situation and they immediately took up the case. We had Jacques sign the necessary paperwork (I don’t recall why he didn’t sign these papers before) and went to court. The unit physician and I testified in support of his being released and the judge ordered his discharge.
Everyone was happy. The patient was certainly happy, as he could return to his job, if it was available. The superintendent was really happy because he wasn’t releasing the patient and he could “blame it on the court” to the Director of Mental Health, who could do the same with his boss, the Governor, who could do the same to the publisher and columnist. The patient never was re-hospitalized and I don’t know whatever happened to him after that.
HOLY TERROR
Our unit was very active and we had many programs for the patients. One of the worst things you can do with a psychiatric patient is nothing. They tend to withdraw and will sit around for hours if you let them. Also, the psychotropic drugs in use at the time caused severe drowsiness as a side effect to their potent primary effects, so it was necessary to counteract these tendencies with active programming.
In addition to group therapy, and individual counseling, case management activities, and community meetings, we had a good social activities program. We had two recreation rooms on the acute unit and some space in the intermediate and chronic wards to social programming if that could be included, given personnel restrictions. We also had a variety of trainees rotate through the unit, including psychology interns and student nurses.
It was probably for these reasons that our unit was held up as an example of good psychiatric programming whenever dignitaries (read “politicians”) wanted to visit or tour the hospital.
One day I received a call from my boss that a certain senator was here with his entourage and wanted to see the unit. That simply meant that the front office would steer these people to those units that made the hospital look good, and so I was asked to come up front to escort them back to our unit. It was a distance of about a two-block walk—all inside. But by the time I got there, they had already received a call from the unit staff that one of our African-American male patients went berserk and they had to evacuate the unit. My boss told me to go back to the ward and “straighten things out.”
Hey, wait a minute! What about security? No, they (meaning he) wanted a clinical person to “talk him down.” So I sauntered back to the unit, and not very gingerly, I might add. When I got back to the ward the place was in ruins. Chairs were strewn everywhere. The patient had thrown a chair through a plate glass window and glass pieces were everywhere. I must admit I wasn’t looking forward to entering the place, and, while I suppose I could have walked through the glass window opening, I didn’t want to cut myself, so I unlock the door and entered. The patients had been evacuated and put in the cafeteria—another one-block walk—again all inside. Fortunately for me, our unit physician was there with the patient, sitting on a couch in the day room. It was clear that the patient was extremely agitated and angry—over what I had no idea, because he had not acted that way in the past). The doctor had convinced him to allow the doctor to give him a heavy tranquilizer shot and was sitting by his side, calmly talking to him. Needless to say, any possibility of a tour was over.
STUDENT NURSES
We had student nurses rotating through the unit as part of their psychiatric rotation. We were pleased to have this opportunity because it gave the patients more people to socialize, converse, and relate to, as part of your efforts to curtail patient withdrawal. It was also useful from a professional point of view because there was an absence of nurses, trained in psychiatry, and willing to work in public mental hospitals. So all in all it was a useful opportunity.
However, one of these student nurses appeared to be getting too close emotionally with one of our younger male patients. He was about 28 or 29 years old, well-built physically but psychotic and diagnosed with what we today would call schizophrenia. She was spending too much time with him, instead of interacting with other patients as well. Also, she was sitting too close with him. Even standing, there was not much space between them. I spoke to her supervisor about it, because the supervisor only periodically was physically present on the unit. However, her behavior did not change. Our team discussed this at one of our morning team meetings, so I spoke to her privately about it.
I told her that while no untoward behavior had occurred—the patient didn’t try to grope her and never made “advances” towards her—he was hovering around her, not relating to any of the other student nurses and was initiating suggestive conversations with her. She apparently thought this was “funny” or “cute,” because she said he was harmless. “No,” I said. “He is not harmless. We have no idea what your exclusive attention means to him.” I asked her to divide her time with other patients as well. This was to no avail.
One day, he escaped from the ward. He went over to the student nurse’s residence, which was several miles away, broke in and tried to accost her. The police were called and he was taken into custody. We never got the details of exactly what he tried to do, and he never was readmitted to our unit so I don’t know the outcome. But this incident served notice to all our trainees and became part of our standing “welcoming” speech to new students when they first appeared on the unit.
THEFT IN THE UNIT
One day I was returning to the unit from a meeting and the hospital police were just leaving. I asked them why they were there and was told there had been a theft there. A student nurse had her wallet stolen. In it was $12 in cash and many credit cards. I asked if they had searched the place and was told they had, to no avail.
This was the third theft we had experienced recently, all from the student nurses. I suspected that it was staff and not patients who had stolen the money and decided to investigate myself. Behind the nurses station was an area consisting of a room we used as a “quiet room,” for “time out” periods and to put violent patients in restraints. It only had a mattress in it. The only place I could look was under the mattress, as there was nothing else in the room. So I did, and there was nothing there.
Down the hall and adjacent to the quiet room was the physician’s office. I ruled out the possibility that the doctor had taken the money, so I didn’t search that office. Across the hall was a coatroom used by staff. I assumed that whoever took the money wouldn’t leave it in their coat, in case there was a search. Next door to the coatroom was the linen closet, used to place dirty linen—primarily patient bedding. I opened the door and the only item in there was a hamper. I opened the lid of the hamper, uncovered a few sheets and pillowcases, and there was the wallet with credit cards but the cash had been removed. I went out into the day room and asked the student nurse if that was her wallet and she said it was. She was very grateful to get her credit cards back, and some of the staff began kidding me, saying it must have been me who stole it since I found it so readily.
I checked the staffing levels to see who had been on duty on all three days that the theft occurred and narrowed the choice down to two of the psychiatric aides. I called my supervisor to tell him of the incident and outcome and asked permission to speak to the hospital superintendent to request that all staff be given lie detectors. He gave me the okay and I contacted the front office and did receive permission to proceed with the lie detection, but was told that it would six months to arrange.
At the next morning staff meeting, I called their bluff and told staff that “enough was enough” and that I had received permission to go ahead and arrange lie detectors to be initiated with all staff. I also said I would be the first one to take it. I never told them that it couldn’t be done for at least six months and I never brought up the fact that I could not force anyone to take the lie detector test, since the union certainly would have objected. I did say that, since it was Friday, that if the $12 was in my office on Monday morning that I would call off the lie detection.
Later that day I took the charge aide aside and asked her to have a meeting with her staff and urge her to have the culprit return the money. She asked me why I assumed it was one of her staff and I told her that a complete review of staffing patterns revealed that only two were on duty during the three thefts and they were two of her staff. She said she would talk with them, but that I shouldn’t expect too much. The following Monday morning I came to work and found an envelope on my desk with the $12 in it. I called the front office to cancel the lie detection test and called my supervisor to give him the news. He said “Well, you win some and lose some.” I so reported to the staff at the morning meeting that the lie detection was now cancelled, as the money had been returned, and I gave it to the student nurse later that day.
FRANCES
Frances was a 40ish African-American female, a chronic psychotic (I don’t remember her official diagnosis) with multiple readmissions to our ward. She usually remitted somewhat rapidly, and then was released with referral to outpatient care, but she never would follow through with the referral.
She had a boyfriend who could easily have been hospitalized along with her, but somehow managed to avoid both the police and concerned citizens. I began to have what I thought would be couples therapy, but after two sessions, I decided this was fruitless and discontinued our joint sessions. When he lost more of his sanity, he would pull a gun on a woman walking across the street—usually alone—threatened her, and then run away laughing before anyone could stop him. He never physically harmed any of these women and, in session, he thought it was funny to see their reactions to his belligerence. I asked him if the gun was loaded or just used as a “prop.” He said “What fun would it be if the gun wasn’t loaded?”
I continued to work individually with “Frannie,” and she got to the point where she had secured a full-time job, which she was to start that Monday. We would give her a pass to go to work and afterwards she was return to the ward. This would continue until we were assured that she could handle the additional stress.
The morning that she was to report for work (in the second shift), we got an order from the superintendent that there was a crazed man in the hallways looking for Frannie and he had a gun. Since we were a locked unit anyway, we really didn’t have to take any extra precautions, but there was the problem of her employment. I sat down with her and told her we were rescinding her pass because her boyfriend was after her with a gun. (I was reluctant to say he was trying to kill her, since he might be now doing to her what he had been doing to other women. Still we were not taking any chances.) I also told her that she should call her new employer, explain that she had a cold and would not be able to report for work for a few days. Meanwhile we had a staff member accompany her to the police station and swear out a warrant for his arrest.
I decided, perhaps somewhat foolishly, that I would disobey the instructions stipulating that staff must remain in the wards until further notice, as I thought I could intervene successfully in this incident. So I left the unit and walked the two blocks (inside) looking for him. When I got to the front door, the normally busy area was completely empty. Where were the security guards?
Me: “Hello. Is anybody here?”
No response.
Me: “Hello. This is Dr. Craig. Is anybody here?
A head slowly began to appear above the front desk, where the security guard had been hiding. So much for a security guard! In his defense, he was unarmed except for a club, so I could understand why he was taking precautions.
Me: “Did you see anybody with a gun up here?”
Security: “No.”
Me: “Have the police been called?”
Security: “No. I don’t think so.”
Me: “Why not?”
Security: “I don’t know. Maybe my boss called them.”
Me: “This incident has been going on for well over an hour. If the police were called, they would have been here by now.”
Security: “I guess so.”
I returned to the unit and we role-played the telephone call, so it appeared natural and calm:
Role-Play Session # 1:
“Hello, this is Frannie V. I was supposed to report to work today as a new employee, but I have a bad cold, so I won’t be able to make it for a few days. I’ll call you every day to report on how I am doing, because I really want to work here. I hope that is okay.”
Role-Play Session # 2:
“Hello, this is Frannie V. I was supposed to report to work today as a new employee, but I have a bad cold, so I won’t be able to make it for a few days. I’ll call you every day to report on how I am doing, because I really want to work here. I hope that is okay.”
Role-Play Session # 3:
“Hello, this is Frannie V. I was supposed to report to work today as a new employee, but I have a bad cold, so I won’t be able to make it for a few days. I’ll call you every day to report on how I am doing, because I really want to work here. I hope that is okay.”
Actual Phone Call:
“Hello, this is Frannie V. I was supposed to report to work today as a new employee, but I can’t come because my boyfriend is after me with a gun.”
She said this with a smile, and was actually proud that he was after her, and even threatening towards her.
She swore out a warrant that afternoon, returning sometime after suppertime, accompanied by a psychiatric aide. I expected that this man would have been picked up by now, but later that afternoon of the next day he called me:
Boyfriend: “Hello, Dr. Craig, how are you?”
Me: “Hello, XXX, where are you?”
Boyfriend: “I’m at home?”
Me: “What’s your address?” He told me.
Boyfriend: “I hear the police are after me?”
Me: “Yes they are. Why don’t you turn yourself in?”
Patient: “No, I can’t do that.”
She had had three other children from different men. All had been removed from the home and been in special education programs. I could imagine how thick their social service files were, given how thick her medical record was. So I did something I have never done with any other patient. Besides referring her for psychiatric follow-up as an outpatient, I included a referral to Planned Parenthood. And guess what? She was planning to go back and live with this guy!
While she was still hospitalized, I received a large envelope from her boyfriend. He had torn out a chapter from a psychiatric textbook. The chapter was on psychiatric interviewing and contained recommended content areas to explore during the interview. Beside each content heading, he had scribbled information allegedly corresponding to Frannie’s history. For example, next to the heading “childhood abuse,” he wrote “Frannie was physically abused by her father.” Next to the heading “education,” he wrote “She was forced to drop out of school to pick cotton in the fields.” Next to the content area “substance abuse,” he wrote “Frannie drinks a fifth of bourbon daily.”
As they say in the Navy, “Now Hear This!” When I met with Frannie to go over this document with her, she told me that this was not her history—it was his!
SEXUAL ABUSE
We had on the ward a 47-year-old African-American female, who had a history of being physically abused as a child by her father. She made good progress on the unit and was being discharged that afternoon. In the morning she was scheduled to be in group therapy with me. I decided to check her discharge plans and she told me she was going back to Mississippi to see her father, who she had not seen in decades. I asked why she had decided to do this and she couldn’t give me a rational answer that satisfied me. I felt there was more to her trip than appeared extant.
I decided to do a role-playing session in group therapy and asked her if she would go along with me. She agreed and I said she should play herself and I would play her father. The scene was at the train station and she had just disembarked from the train and saw her father standing there waiting for her:
Me: “Honey, I’m so glad to see you after all these years.”
Patient: “You son of a bitch!”
She stood up and came at me with her umbrella raised in her hand and she was about to strike me. I stood up and raised my arm to block the blow.
Me: “Sarah, I’m not your father.”
She stopped and smiled and sat down. I tried to get her to reflect on her behavior, on what she was feeling at the time, and pointed out to her that she felt this way when I wasn’t even her father. What would she feel and how would she behave when she actually saw him? But she just laughed it off and said she was still going.
Sorry. I have no follow-up on this patient.
EXORCISM
One of my favorite stories concerned a 30-year-old Hispanic female who was admitted with paranoid delusions, claiming she was possessed by the devil. The doctor tried her on several different medications, but she did not respond to any of them.
I happened to know a Hispanic priest, and asked him if he was willing to perform a “fake exorcism.” I asked him to spend some time with her in her room. We would invite her closest family, and he would say prayers in Latin, telling her he was performing an exorcism, but not a real one. He agreed, much to my surprise, and one afternoon, they congregated in her room, where he spent a half hour there behind closed doors, praying over her while she lay on bed. Two days later, these delusions had completely disappeared and she was discharged.
POST-DOCTORAL FELLOW
We received a request from a psychologist who wanted to do a post-doctoral fellowship at our hospital, so we developed a yearlong training experience for him. I was assigned as his supervisor for individual psychotherapy. I referred patients from our unit to him for psychotherapy and supervised him by listing to the audiotapes he was required to provide me. We met weekly.
He was a 35-year-old African-American male psychologist, and I must say I was appalled after listening to his first psychotherapy session. We didn’t really hit it off, because I was quite critical of his work and felt he was not doing psychotherapy. Of course, he disagreed. At issue was the fact that the content of the session(s) largely consisted of him suggesting ways to get a job. I accused him of doing social work and not psychotherapy. He said you can’t do traditional psychotherapy with such indigent people and first you have to address their basic needs. I told him then to refer the patient to a social worker. Again, he disagreed.
I tried to reassure him that this issue would not lead to a negative evaluation on my part because he was trying to help the patient and his sincerity shown through. I wanted him to feel that he could speak his mind, and disagree without fear of retaliation on my part. Meanwhile, I began to read up on doing psychotherapy with minorities. Today there is required coursework on this subject in our graduate schools but then, there were no such opportunities and we were taught traditional psychotherapy techniques independent of who was on the receiving end.
Meanwhile a body of literature began to appear that questioned whether minorities were amenable to psychotherapy. A subsequent body of research demonstrated that minorities do just as well in psychotherapy if the therapy is adjusted to address their problems and needs in ways that provide them with solutions to their concerns.
So in the end, we were both right, and we were both wrong. He did adjust his counseling techniques in a way that was more palatable to my way of thinking and I didn’t challenge him anymore when he started doing “social work” in the sessions. I guess we both learned something, because, later in my career, I found myself doing many of the things that this man was doing with his clients “way back when.” He was ahead of the times.
THE ROLLING STONES
As I said before, we had a number of good programming activities for patients. I had made arrangements with one of the local universities for students to come weekly to interact and socialize with the patients. These were psychology majors and I thought it would be good experience for them, and benefit the patients as well. Things were going fine until one day:
Volunteer: “Dr. Craig, my buddy and I play the guitar and sing. Would it be okay for us to play for the patients?”
Me: “Sure, that would be fine.”
Volunteer: “When do you want us to come?”
Me: “How about next week?”
Volunteer: “Okay, fine.”
Now I play the guitar and I know that musicians have a group of songs called a “set” that they sing and each song follows the same song in the same order. So they came the following week and started playing. They were fine and the patients were enjoying it, but they had to play this set and they didn’t think about the name of the songs or the setting in which it was being sung. So they played song number three and went right into song number four. And song number four was the Rolling Stones song “Here Comes that Nineteenth Nervous Breakdown!”
Staff were looking at me and rolling their eyes and I was quivering in my boots. So I had to have a little talk with them after they finished their set. They were quite embarrassed, but I hope this was a positive learning experience for them.
Now the only thing I could add was the possibility that the patients weren’t paying attention to the words. The following example might tend to illustrate what I mean:
My son, while in high school, played the drums and was in a band. His band practiced in my basement, where I also had an office. One day I was in the office and the band came over the practice. Needless to say, the walls were not soundproof and their music came resounding into my office. The song they were practicing was written by their lead, writer Kevin U. It was called “Streets of the City.” For some reason, new lyrics immediately popped into my head and I rewrote the song. I practiced the chords on my acoustic guitar, opened the door and announced that I had new lyrics for their song and would like to play it for them. This was the chorus:
If you go to the streets of the city
And hear the jam boxes playing away
Don’t try to memorize the words
‘cause you can’t hear them anyway.
I hoped that was the situation with the patients. They just didn’t hear or pay attention to the lyrics. Anyway, no patient ever mentioned this to any of the staff, so it turned out okay.
PSYCHOLOGY STUDENTS VISIT THE UNIT
I was teaching an undergraduate course in community psychology to a group of psychology majors, and offered them the opportunity to come and visit our unit and spend an evening with the patients. I thought it would be a good experience for them as well as providing patients with some hopefully stimulating interaction during an evening which tended to have less programmatic activities going on. Instead of letting them “wing it,” I carefully selected a range of patient problems and diagnoses and gave them the task of finding out “what was wrong” with the patient. Many had made a suicide attempt, leading to their hospitalization. Others had become violent with a family member, while still others had acted up in some way within the community, causing the police to bring them to the hospital. I delineated their task but instructed them to make sure the interaction felt like a social conversation and not yet another psychiatric interview. They spent three hours in the ward that night. We processed their interactions and “findings” at the next class. I thought it was a positive experience for all concerned.
KEEP THEM IN THE COMMUNITY
The hospital decided that it no longer wanted to treat patients. Well, that’s not how it framed the policy change. It believed that the patients would get better care if community professionals treated them in the community. This was part of a major shift, nationally, in the mental health system in the United States, whereby the locus of care was shifted from large state institutions to smaller, community-based entities.
I generally disagreed with that policy change, and had several discussions about this with my boss. One evening we were in a restaurant having dinner after work, preparing for a meeting we were scheduled to have with some community representatives. Once again we were debating the value of treating patients at our hospital or referring them for treatment with the group about which we were planning to meet. I was voicing my disagreement when women sitting alone across from me asked for my attention.
“Excuse me. Did you know the soup here is poisoned?”
I turned to my boss and said “Keep them in the community!” My boss simply said that if you work at a place, you have to accept the philosophy of the institution or else leave it. So I did—leave.
I recently had moved into a new apartment. The only person in the neighborhood I knew was our landlord in the apartment below. One summer evening as I was walking outside to throw out the garbage in the container in the alley, the next-door neighbor was watering her grass in her backyard. I said hello.
The neighbor replied, “Did you know the neighbors are poisoning the grass?”
“Well,” I retorted, “then don’t eat the grass!”
She laughed, but as it turned out she was totally paranoid. At least she wasn’t dangerous. I tried to avoid her whenever I could, but I was the only one in the area that she would talk with. I don’t know why she felt safe with me or why she never accused me of poisoning her grass, but she did talk to me whenever she saw me. Of course, it was all paranoid ramblings, mostly of persecution. Maybe I’m cursed.
HOLY CHRISTMAS!
During the Christmas, the institution had placed a nicely decorated Christmas tree in the front lobby. I thought it lifted one’s spirits as we reported for work in the morning. One day, as I arrived and entered the area, it was lying on its side, with ornaments and Christmas tree lights strewn about the floor. I assumed that an angry patient had gone off in a fit of rage. People were standing around and so I asked someone what had happened. I was told that a female psychiatric resident had gone into a screaming fit, torn down the tree and run into the women’s bathroom. Policemen had gone into the restroom to restrain her. They brought her out in handcuffs.
Later I learned that she had had a psychotic episode and was sent for psychiatric care. Now I would have assumed that the residency training program would either try to dissuade her from entering the psychiatric profession or else remove her form the training program. I was wrong. After several months, she was back at her residency. I understand that there must be some sort of laws that prohibit such actions—you know, civil rights—but it seems to me that there are some kinds of people that just shouldn’t be in our profession.
Another possibility is that the residency program directors and medical schools are reluctant to “muster out” candidates. Later, I became aware of a psychiatrist at another hospital who was not considered competent. The patients and even the staff complained to me about her. I went to her immediate supervisor and listed specific incidents that clearly should have reflected on her problematic behavior. He told me he was not going to tell her how to practice medicine. Later she made a serious and near-disastrous change in medicine that could have been fatal to the patient. Finally, another physician made the formal complaint, and, upon review, they removed her clinical privileges. Thus she could no longer treat patients. Later I learned that she had had problems during her residency. The program director didn’t want to pass her, but, given what she had been through to escape a communist country, they decided to give her a pass.
STAFF PARANOIA
It is well known that, among seriously disturbed mentally ill patients, staff behavior can benefit or harm patient behavior. For example, clinical staff are taught to portray and present a calming demeanor when interacting with patients, because such an approach has a calming influence on them. A more cogent example is below.
I attended a three-day training conference on suicide assessment, intervention, and prevention. As part of the training, we watched the movie One Flew Over the Cuckoo’s Nest, which illustrated Nurse Ratched’s over-controlling demeanor and behavior harming patient (and staff’s) coping behavior amidst a psychopathic resident, who managed to get the mentally ill patients to act out his own nefarious motivations. The following story illustrates this all too well.
There was a time during upcoming state elections that the opposition party held hearings about how “terribly” the mentally ill were being treated in the State institutions. The real motivation was not to improve the treatment of the mentally ill, but rather to embarrass the governing party and help sway the elections to the other side. Such was the environment when I began a new assignment at the hospital, as director of an acute admission psychiatric unit. This was a particularly sensitive issue for me, as I was designated as the first non-physician to head a psychiatric unit in the state psychiatric system. (Actually, as I have already told you, one of my colleagues preceded me as the director of the alcoholic treatment unit in the hospital, which caused the physicians to demand a meeting with the superintendent—a physician.) As a result of the meeting, the physicians rationalized that the alcoholic treatment unit was on the grounds separated from the main psychiatric units and hence “was not really a psychiatric unit.” This rationalization appeased them. However, when I was made a director, there was no rationalization possible and I felt a keen need to do well and get them on my side.
At my first staff meeting with the Superintendent and the other physician ward heads, the following conversation occurred in the meeting. I had been there only a few weeks, when the Superintendent said, “Dr. Craig, how come there is a higher incidence of fevers on your unit?”
Now I always believed that the best defense is a good offense, so I replied, “Maybe these things go unnoticed on the other wards!” Everybody laughed.
“I don’t know. I suggest you send the nurse epidemiologist to our unit and explore the matter.” This was done. Now back to the main story.
For the first week, I was careful not to offend the unit physician, who had been there for a few years and was used to doing things his way. He had a good clinical staff working with him but there was little organization and the main goals of the unit—to discharge a patient within 30 days or transfer the patient to one of our intermediate care wards—was not being done to the satisfaction of the hospital. As far as the organization was concerned, this unit was retaining patients too long and they wanted someone to come in who would advance organizational goals. So the dilemma for me was to gain the confidence of staff to change the milieu, while advancing its morale. The clinical staff professed support for me at first, and advised me to go a bit slow until they could adjust to the new “regime.”
I was careful not to disrupt things too much, but I had goals to accomplish and didn’t have much time to try them. One of the treatment interventions that is practiced in most psychiatric hospitals is termed “milieu therapy.” By this we mean to structure the environment itself so it is therapeutic. One of the hallmarks of milieu therapy is an intervention called “community meetings.” Here the staff meets with patients as a group and tries to address patient complaints as well as promote positive patient behavior. In psychiatric units with longer lengths of stay, sometimes they used “patient government” as part of the milieu therapy approach. Here the patient community elects officers (president, secretary, and sergeant of arms) who conduct regular meetings with all patients on the unit and all clinical staff. Sometimes the units allow patients to vote on giving passes and even recommend discharges, although these are advisory and clinical staff makes the final decisions. The idea behind such interventions is to maintain patient involvement and resist ideational regression.
This unit held community meetings with the patients thrice weekly. After a few days of my new assignment, I met with staff and told them that these meetings were at variance with the goals of the unit. These meetings (a) actually promoted identification of the patient with the unit and (b) detracted from staff time better suited towards interventions and discharge. So I announced I was eliminating them from our treatment program and transferring the community meeting to the evening shift, where the clinical staff assigned to that shift could meet with the patients once a week. Also eliminated was the need for patient officers, as I couldn’t see the purpose of them, especially since the better functioning patients were typically voted in as officers and these were the ones more easily discharged. Thus, the purpose of these meetings generated into constantly electing new officers.
The staff saw the logic behind this decision and did not object. I felt pleased with how they took the news and saw this as a sign of support I really needed. The unit physician, though used to making decisions prior to my arrival, was not concerned about this, considering it trivial.
There is an old saying that if it walks like a duck, talks like a duck, and acts like a duck, then it is a duck. Translating this adage to the immediate situation, I was determined to walk, talk, and act like I was in charge, and so to be in charge. I could have met with the unit physician privately and told him of my decision or mentioned to him that this was what I was planning to do and seek his opinion, but then I would be acting like he was still in charge, so I didn’t. When he didn’t object in the meeting, where the announcement was made, I was hopeful that he was accommodating and adjusting to the change of direction, including my leadership. I was wrong.
Within two weeks of my taking over the psychiatric unit, public hearings began at our hospital. The political party announced that hearings would begin on Monday and solicited those willing to testify before the committee. There was widespread publicity about this event in the daily newspapers, and a slew of reporters and newsmen were present to film and record these testimonies.
The first person to appear was the state director of mental health, who had just been appointed by the governor a few months ago. The committee grilled him about conditions at the hospital and asked him a plethora of questions he was unable to answer, mostly because he hadn’t been around long enough to properly address them. He frequently responded by suggesting the committee address that question to the hospital superintendent, which was more appropriate, but which resulted in a spate of angry responses from the committee members, who were motivated to embarrass the governor.
The next witness was the hospital superintendent, who was a more credible witness, as he was more familiar with the rules and regulations of the Department of Mental Health and the regulations and administrative workings of the hospital. After the superintendent finished his testimony, the committee heard from current and former patients, clinical staff at the hospital who wished to testify, and from community members. This continued for the next two weeks.
One of our current patients had volunteered to testify and issued a number of complaints about a myriad of matters, and was generally negative about the hospital. He testified early in the afternoon, and many of the unit staff were present to hear his testimony, including me and the unit physician. Immediately afterwards, I learned that the physician was planning to discharge him. I went to see him privately, and asked if he would have discharged this patient today had the patient not testified, especially in such a negative light. He told me no, but it would be better that he not be around to negatively reflect on the hospital. I told him this would look vindictive and was not a good idea. He erupted in a flurry of rage that probably had been pent up since my new assignment. He told me I was an upstart to tell a doctor what to do, that I had no business making changes, that he was in a better position to deal with patients and staff, and that I should mind my own business.
I responded by saying I was not telling him what to do, but merely advising him as to how it would appear to others if some untoward event occurred after the patient was discharged. I said I was assigned here to make changes and if he disagreed with these and we were unable to work it through by talking with each other, then he could take up the matter with my immediate supervisor. Finally I told him unit functioning was my business. Later in the day, some of the clinical staff, who had worked with him for a few years, also talked to him, agreeing with me, and he subsequently changed his mind. Such was the environment when a patient that I called Sam was admitted on Saturday.
Our unit was a 28-bed psychiatric unit with an average daily census of 45. Every weekend we had anywhere from 20 to 30 patients admitted. It was not unusual for us to have over 75 patients on the unit every Monday. The first task every Monday morning was to discharge 20-25 patients or transfer them to intermediate care wards if we were unable to discharge them. We had criteria to go by when transferring patients; we couldn’t just transfer them willy-nilly. We were quite excited whenever a patient was admitted who was a veteran because we could easily transfer them to a VA hospital. They would always agree to the transfer. I reviewed every admission and assigned the cases to clinical staff, including myself. Again the task was to determine who could be transferred, discharged, or could be discharged within the 30-day maximum care that was our unit goal.
I interviewed Sam that Monday morning. He was from the East Coast and had been married only after a few months when his wife tragically died in an auto accident. After the funeral, he had gotten on his motorcycle and the next thing he remembered was being admitted here.
Crisis intervention is a theoretical approach with a set of prescribed intervention techniques that purportedly will reduce the crisis and eliminate the emotional sequelae and forestall personality regression than often results from an improperly addressed crisis. I was just learning this approach, and while this patient could have been discharged (or so I thought), I also felt it would be better for him in the long run if we kept him here and worked with him around this crisis (as well as for me in having the opportunity to practice this intervention, which required daily individual therapy for a total of six sessions). I told him that he had a fugue as a result of this emotional trauma and that I would work with him daily and that his length of treatment would be about 7-10 days. The following morning, I told staff about the case and my treatment plan for him.
We had a psychology trainee on the unit who lived in the vicinity of the address the patient provided upon admission. For a reason I never inquired about, he said in the Tuesday staff meeting that he had gone to that address, which was a large apartment building, and there was no such person listed in the building mail boxes. I didn’t consider that unusual. If the patient was from out of town, he may have just made up an address,to ensure he would be admitted. Maybe he was just looking for a place to stay and some regular meals, “three hots and a cot.” After my therapy session with the patient, I mentioned to him that a staff member checked the address he gave us and there was no such person there. Sam said he didn’t tell me the whole truth. After his wife’s funeral, he had gotten on his motorcycle and wound up in Chicago. He had met another girl and moved in with her. He was ashamed to tell me that because he didn’t want me to think he didn’t love his wife. This girl invited him to stay with her until he got settled. He said there was nothing going on sexually between them. He gave me her name and I asked the student to check it out.
The next morning, Wednesday, the student told he there was no such person listed at that address, so I didn’t tell Sam about this but asked him to take a psychological screening test, called the Minnesota Multiphasic Personality Inventory. This was a 566-item (the current version contains 567 items) paper-and-pencil test where the respondent answered true or false to a number of symptoms, traits, attitudes, and interests. The following morning, Thursday, I read the evening nursing notes and a psychiatric aide reported that, upon entering Sam’s room, he appeared to have some type of cheat sheet with him and he was copying answers from the cheat sheet to the test answer booklet. We discussed this new information the Thursday morning staff meeting. We were all now convinced that Sam was an undercover reporter sent here to investigate the conditions at the hospital and how patients were being treated. What added to our convictions was the fact that we observed no clinical symptoms. The patient was relating well with the other patients, was having no sleeping problems, seemed in control of himself and the unit physician did not see a need to medicate him. The evening nursing notes were continuously positive about his behavior.
I instructed the staff not to treat him any differently than any other patient, but to make sure that we documented well his behavior and condition, as we are required to do with all of our patients. I then called my boss:
Me: “Gary, I believe we have an undercover reporter on the unit.”
Boss: “Not likely. No normal patient can exist 24 hours on your unit without being psychotic.”
Me: “This is not funny, Gary. This could be serious.”
Boss: “Okay. Why do you think he’s a reporter?”
Me: “His story seems full of lies and without corroboration and internal consistency. He’s showing no clinical signs of any psychological condition or psychiatric disorder. And an aide observed him apparently trying to fake the MMPI. I asked him to take this test and he seemed to have answers on another sheet. There are plenty of ways someone can get answers to this test. They can buy any MMPI text and get them, especially if he wants to appear to have a certain condition on this test.”
Boss: “What did the test results show?”
Me: “I don’t know. He hasn’t completed the test yet. But I don’t think I could rely on the findings anyway.”
Boss: “No, but it would give you further ammunition or evidence, one way of the other.”
Me: “When I get the results I’ll let you know and will keep you posted on any developments, but I think you should notify the superintendent about our suspicions.”
Boss: “You’re probably right, but I still don’t think he’s a reporter.”
Meanwhile, a psychiatric aide told Sam we thought he was a reporter, so when I approached him for our regular session that day, he was irate and obstreperous. He spent most the session attacking me and the staff and demanded to testify at the next Committee meeting. Of course, any real psychotherapy or crisis intervention was over, as therapy relies on mutual trust and that had been destroyed. I gave him the information on how to request to be a witness at the hearings. He told me that his brother was a reporter for the magazine, Psychology Today, and he would hear of this and how we were treating him. I asked for the name of his brother, which he gave me. This magazine was based in Del Mar, California, so I called the Human Relations department of the magazine, who reported they had no such person on their payroll.
The physician ordered a fasting blood sugar and glucose tolerance test. When I came to work Friday morning, the patient was in full leather restraints and totally psychotic. Whether it was the stress of the fast or the stress in the environment that we put on the patient, his façade was lifted and his true self became manifest.
Later that morning, I received a call from Sam’s brother, inquiring about his condition. I told him, not about our suspicions, but about his current condition, including that fact that he had an episode overnight and had to be put in restraints. His brother told me that the patient had a chronic psychiatric condition in which he impersonates a particular role. He said he once convinced the Chicago Tribune that he had been playing quarterback in the Canadian football league, and that the Chicago Bears has just signed him as a backup quarterback. He even tried to enter their training camp, where he was arrested and hospitalized. You may recall incidents when a person dresses up as some public persona and then acts out that characterization, often in violent and homicidal ways. The condition exists. Though rare, I have seen it.
Later that afternoon, we finally received the medical records from his previous hospitalizations. The folder was three inches thick. With many current medical records now computerized, such occurrences become unlikely, but the fact remains that clinical staff can have a profound effect on patients.
WEIRD—BUT NOT A PATIENT
During graduate school, I had to take two courses in experimental psychology. There was a textbook, assigned readings, and a lab, where we had to conduct experiments on each other as subjects. That wasn’t enough of a sample size, so we always had to go out and recruit more test subjects. I relied heavily on my fraternity brothers and close friends to accomplish this task.
One of my classmates, Al, unfortunately for me, was my lab partner. We had to do many experiments as a team. He always screwed up every experiment we tried to do, especially when he was one of the subjects. In reaction time experiments, his reaction times always threw off the group mean. In experiments of memory and concentration, he always took the longest to learn the material. In one of the experiments, we had to pre-screen the subject for color-blindness using the Ishihara plates. You guessed it: he was color blind, and said he never knew it. At the end of the end, our professor held a luncheon and gave out awards. Al was given the award for the “worst test subject” he had ever had in class.
I lost track of Al after graduation until, out of the blue, he called me and said he wanted to come to the hospital and talk to me. I asked what it was about and he said he didn’t want to talk about it over the phone. We agreed he could come the following week for an afternoon appointment.
Given his previous behavior, I expected him to come late, but he arrived on time. There was something unusual about him, but I couldn’t quite put my finger on it. He said he had been working at a local prison but had lost his job under some questionable circumstances that he tried to smoothe over. Basically he wanted a job and asked me to hire him.
Now we had no openings, but I certainly wouldn’t have hired him based on his previous class performance and the fact that he had worked with inmates and not psychiatric patients. His present demeanor didn’t inspire confidence either. He said he had tested and interviewed “Calvin,” and, if I hired him, then we could publish a book of this person together.
Now Calvin was a well-known criminal in our part of the country. He had entered a student nurse residence, herded eight nurses into a room, locked it, tied them up, and systematically raped each woman and then killed her. One of the students got loose from her bonds and hid under the bed. Later, she was the key witness at his trial where he was found guilty and sentenced to life in prison, I believe. Al told me that Calvin told him that he probably did it, but doesn’t remember any of it.
Again I told Al that we didn’t have any openings—which was true—and that I wasn’t interested in pursuing any publications with him, as I was too busy. Of course, there were other reasons for not wanting to get involved with him, but that sounded better than the truth. I lost track of Al, but, later Calvin was filmed, nude in his jail cell with enlarged breasts (gynocomastia) where he was snorting cocaine just before he was about to have sex with an African-American male inmate. Calvin eventually died in prison from natural causes.