CHAPTER TWO

It was a few days later that Alex exploded in school, smashed the clock in the hall, and ran from the principal. That was the April night I found myself in the car, following an ambulance, on a deserted highway. Alex was admitted to St. Clare’s Hospital in Boonton Township, New Jersey, on April 19, 1996. I wasn’t easily able to accept what had happened. One day, Alex was a kid having trouble in school. The next, he was a patient in a locked hospital ward. It had happened too fast. Before I could adjust to the idea that Alex might need to be hospitalized, he was already there.

At the hospital, as Alex lay on a gurney beside the open door of the cramped admissions office, I fumbled with the admission forms. I was ill-at-ease, and clumsy. I wanted to ask what would happen next, I wanted to meet the doctors, I wanted to know what they would do, how long it would take for Alex to get better, and when he could come home. But I couldn’t get any of those questions out. I couldn’t think clearly. It took all the concentration I had to fill out the forms and answer the insurance questions. On the long drive home that night, I hunched over the steering wheel. The highway in front of me softened to a watery blur. I wiped away the tears. Liz and I did not speak.

Later, I made notes for a poem I have never completed. I wanted to write something about being battered by powerful winds—the “winds of hell,” I wrote melodramatically in my hasty notes. I imagined myself standing on barren ground, with all the trees blown away, so there was no shelter. I leaned into the wind, fighting to remain upright. Next to me, I saw an eleven-year-old boy, also fighting to stand upright, but because he was smaller and lighter, he was nearly being carried off. He looked up at me. I wanted to help him, to keep him from flying away, but I couldn’t reach him. I could see the fear and uncertainty in his eyes. Help me, he seemed to be saying. You’re my father. Hold on to me. Hold on.

Alex had been admitted on a Friday, not a good time to enter a psychiatric hospital, as I found out. Except in an emergency, psychiatrists and other therapists see patients mostly on weekdays. It would be two days before we would find out much about his condition. At least the hospital kept him safe over the weekend, something I wasn’t sure I could do at home. We were able to visit, but we were in a holding pattern, waiting.

On Monday, we met with a social worker. She asked a lot of questions about Alex, the family, his brother and sister, his friends in school, and what we thought about his emotional condition. I told her that Alex had seemed to deteriorate on the Zoloft, which he’d now been taking for several weeks. The angry outbursts had become more frequent and more severe. He threatened suicide often. The social worker had asked Alex many of the same questions, trying to put together a history that could help lead to a diagnosis. Alex told her he could not remember his angry outbursts when they were over, that he often felt sleepy afterward. He said that during one recent outburst he had heard two voices, one telling him to stop and the other to continue. He said he had experienced mood swings that lasted up to a day, teetering from depression to wild elation. These had become more common during the preceding two weeks, he said. He was given a battery of routine blood and urine tests; all were normal, the social worker said.

Alex had also been examined by one of the hospital psychiatrists. Taking a different approach from Alex’s first psychiatrist, this one wanted to rule out the possibility that Alex’s behavior was the result of some kind of seizure. Psychiatrist No. 2 consulted a neurologist, who suggested that Alex be given a “sleep-deprived EEG,” a brain-wave reading done after he’d been kept awake all night, so that unusual brain activity might be more likely to show up. He also ordered a CT scan (what used to be called a CAT scan) of Alex’s head. The hospital staff had monitored Alex closely throughout the day, looking for any indication he might try to hurt himself. They saw none. Alex kept to himself in the morning, but by the afternoon was participating in group therapy sessions and recreational activities, the social worker reported. A nurse asked Alex whether he had had any traumatic experiences. “Probably being in here is the worst thing that ever happened to me,” he said.

Psychiatrist No. 2 had started Alex on Tegretol, a medication first used to treat seizures and now prescribed for a variety of psychiatric ailments. Uncertain whether Alex was suffering from a seizure disorder or a psychiatric illness, he was covering both possibilities with a drug that might be helpful in either case. I began to get a sense of how imprecise and subjective psychiatric treatment can be. Psychiatrists mix and match medicines for all kinds of reasons. Occasionally they have scientific evidence to back up these treatment decisions, but more often they are acting on experience, because the appropriate scientific studies have not been done. Some medicines are used for so many psychiatric ailments that I wonder whether they have any effect at all.

The social worker closed her file, stood, grabbed her keys from the desktop, and led us down the hallway to see Alex. She unlocked the door to the ward, waited as we followed her in, and turned to lock the door behind her. Alex was in the common room with a dozen other kids. He dropped what he was doing and came over to give Liz and me a hug. He looked sad. When we asked him why, he said, “There’s nothing to talk about.” We spoke briefly. None of us had much to say. It was tough to make conversation when all we could think about was what was wrong and when he was coming home. Alex wandered into another room, where the rest of the patients were watching a movie. He took a folding chair near some of the other kids and moved it away before sitting down. He sat alone, refusing to talk to the staff or the other kids. We said good night and left him there.

Alex was a little agitated that night and was having trouble falling asleep. He was given Benadryl, the allergy medication. Its drawback as an allergy medicine is that it induces sleepiness. In psychiatric hospitals, it’s prescribed for precisely that reason, as a mild sleep inducer. The next day Alex participated in all of the group’s activities. But each time, he started in a chair at the edge of the group, and then slowly joined the discussion and moved closer. He talked about how much he hated school. He complained about the arguments between Liz and me. “I’m afraid they will get divorced,” he said. When asked whether he had any good qualities, he said, “I’m kind to my dog.”

On his third day in the hospital, Alex became agitated. He spent the morning in the “quiet room,” a small room used to confine patients who become angry or agitated and cannot be soothed, to ensure that they don’t hurt themselves. A quiet room is empty except for a mattress on the floor. Left alone there, some children are able to calm themselves. Some require sedation. Alex was released after lunch, protesting that he had not done anything to deserve confinement. During one of the three, hour-long periods each day during which patients were allowed to call home, Alex called his mother to complain about his treatment. He got angry with her and hung up. He was again sent to the quiet room. He banged on the door, demanding to be let out. The staff tried to work with him, to find out what was wrong. But he refused to talk to them.

The next day was a good day, and we all knew that was important, because good behavior counted toward getting him out of there. The cause of his “recovery” was as mysterious as the cause of his outbursts the day before. He was cooperative and remorseful. The hospital staff said he’d taken an interest in some of the younger patients, and was helping them adjust to the hospital. He was doing so well on this, his fourth day in the hospital, that the staff began to plan for his discharge. They had made no progress in diagnosing Alex’s condition. The hospital was having some sort of scheduling problem, and he still had not had the EEG or the CT scan that had been ordered the first day but could not be done on the weekend. I was afraid that he would be discharged without those tests, and that we might miss a critical clue about the cause of his distress. I was afraid that his behavior might be the result of some sort of atypical seizure disorder or, worse, a brain tumor, and that he would be discharged before it was found. Maybe it was something that could be cured if dealt with quickly. I was assured that the tests would be done. Alex’s social worker scheduled a family therapy session for the next day.

I left work early for the two-hour train trip to the Boonton Township station, near the hospital but too far to walk. Liz was supposed to pick me up at the station on her way to the hospital. Somehow, we had crossed signals, and she went directly to the hospital. While I was standing on the platform, fretting over the time and wondering what had happened, the social worker canceled the family therapy session, because I wasn’t there. Liz found me at the train station an hour later. We argued about who had been responsible for the missed connection. The family therapy session was not rescheduled. Alex had had his sleep-deprived EEG and CT scan, and both were normal. He was scheduled to be discharged on Friday, April 26, one week after being admitted.

Alex beamed when he was told he would be leaving. It was easy to forget the state he’d been in only a week earlier. He looked much stronger. The dark circles were gone from his eyes, and he was eager to see his brother and sister. He wanted to see Reggie, our Scottish Terrier. He told the staff that he had learned a lot about himself during his stay, and they were pleased with his improvement. He said the hospital stay had helped him and he expected to do much better at home and at school after his discharge. We drove him home, bought him pizza, and celebrated his return. It was like welcoming him home from summer camp. I was relieved, and happy to have him home, and I set my worries aside for the evening.

But they returned the next day. Alex still had no diagnosis. He had had only minimal therapy, a session or two a day for less than a week. When he was discharged, he had been on Tegretol for three days, far too little time to determine whether it was helping. It was tempting to believe that the problem had been solved. But I was skeptical. I couldn’t see how such a short stay in the hospital could do much of anything. The hospital had kept Alex safe, when he needed to be kept safe, and Liz and I had had a chance to talk about Alex with Psychiatrist No. 2 and a social worker. But they didn’t have any answers. We had a long, thoughtful conversation with the neurologist, who said he didn’t think Alex had a seizure disorder or a brain tumor, but that he would need more tests if we wanted to be certain.

The hospital discharged Alex on the condition that he continue to receive psychiatric treatment, but didn’t direct us to anyone who could provide that treatment. Psychiatrist No. 2 had undone the work of the first psychiatrist Alex had seen, dropping the Zoloft in favor of Tegretol. I started to keep score: this was Alex’s third drug, after a total of three visits to two psychiatrists. Each visit seemed to generate a new hypothesis and a new treatment. I didn’t know anything about how psychiatric diagnoses or treatment decisions were made, but this seemed wrong. I wanted to get Alex set up with a good child psychiatrist who could spend some time with him, get to know him, and make a treatment decision based on more than twenty or thirty minutes of conversation. The hospital staff agreed. But when I asked whether they could recommend a good psychiatrist for us, they said, Sorry, we don’t know any in your area. So what now? I asked the hospital staff. Where will we go for help? We really wish we could help you, the kindly social worker said; Alex is such a bright boy. Best of luck.

With no child psychiatrists on the insurance company’s preferred-provider list, we had to abandon the list. We asked Alex’s school psychologist to help. He recommended that we take Alex to see a local psychiatrist who knew our community and its children. We made an appointment. Psychiatrist No. 3.

Alex seemed fine during the first weekend after his discharge, except for an episode of uncontrollable laughter. On Monday morning, however, he refused to go to school. “I’m not going. Get away from me!” he shouted at his mother. He pulled his hair, thrashed around on the bed, and eventually calmed down and fell into a deep sleep. He spent most of the day in bed. His outbursts were often followed by a deep, trancelike sleep, after which he couldn’t recall what had happened.

Psychiatrist No. 3 had a large number of patients with attention-deficit/hyperactivity disorder, or ADHD, one of the most common brain disorders in children. He was treating many of them with Ritalin. After his visit with Alex, Psychiatrist No. 3 concluded that Alex, too, was suffering from ADHD. He stopped the Tegretol and started Alex on Ritalin. He added Ativan, an antianxiety drug that he thought might help with the more ferocious emotional swings. But Alex’s condition began to deteriorate as soon as he started taking the medication. His outbursts became more frequent and more severe. It seemed to me that these psychiatrists were diagnosing a complex emotional problem and dispensing medication with no more care or deliberation than if they were swabbing Alex’s throat for strep and sending him away with penicillin. I updated my tally: three psychiatrists, four visits, four drugs. All within less than two months.

I’m not sure why it seemed so crucial to get Alex a proper diagnosis. Partly, I suppose, it was because I wanted to get him the right treatment, and I wanted to know what his prognosis was. Would he get better? Would he struggle with this for the rest of his life? Without a diagnosis, it was hard to know what to think.

Much later, I learned that proper diagnosis is not easy. “Diagnosis in psychiatry is a problem” and “distinguishing between normal behaviors and pathological ones in a young child is even more challenging,” writes Dr. Demitri Papolos, a psychiatrist in Connecticut and the coauthor, with his wife, Janice, of The Bipolar Child. Children are constantly changing, developing, and growing, so it’s hard to compare their lives before the onset of illness with their lives afterward. And it can be hard to sit them down for a thoughtful conversation. “Children are often misdiagnosed,” they write, or plastered “with a literal alphabet soup of diagnostic labels: attention-deficit disorder with hyperactivity (ADHD), obsessive-compulsive disorder (OCD), oppositional defiant disorder (ODD), conduct disorder (CD), generalized anxiety disorder (GAD), and so on.”

In cardiology, a diagnosis can be as neat and quick as the snap of the needle on an electrocardiograph. But there is no measure for depression, no blood test to identify schizophrenia or mania. In psychiatry, diagnoses overlap and flow into one another, blurring like the colors on an artist’s palette. Instead of making a diagnosis and then choosing a drug, it often seems that psychiatrists will choose a drug to help make a diagnosis. If a patient responds to lithium, she has bipolar disorder, otherwise known as manic depression. If she does better on an antipsychotic, she has schizophrenia. If a child seems calmer on Ritalin, he has attention-deficit/ hyperactivity disorder.

Psychiatrists disagree so often and so profoundly about their diagnoses that they have devised a cookbook of symptoms to help them out. This book, the Diagnostic and Statistical Manual of Mental Disorders, which is published by the American Psychiatric Association, is unlike anything you’ll find in the office of a cardiologist or an oncologist. DSM-IV, as it’s called (the current version is the fourth edition), lists psychiatric symptoms and reduces diagnosis to a complex multiple-choice quiz. You might think, for example, that diagnosing a manic episode in a person with bipolar disorder would be relatively simple. It seems easy enough to any parent who has had to help a child get through a manic episode. Not so for psychiatrists, however. In their zeal to make their diagnoses accurate, they have devised elaborate checklists that exclude many patients who need help. DSM-IV lists five criteria for a manic episode, for example. This is the second of the five, with its seven subsidiary benchmarks:

During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:

inflated self-esteem or grandiosity

decreased need for sleep (e.g., feels rested after only 3 hours of sleep)

more talkative than usual or pressure to keep talking

flight of ideas or subjective experience that thoughts are racing

distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)

increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation

excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)

A child with three of these satisfies one of the five principal criteria for mania. Only two, and he doesn’t. DSM-IV also includes a sly acknowledgment, in the small print of a footnote, that doctors trying to diagnose mania can just as easily cause it: “Note: Manic-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis,” it says. In other words, if the mania was caused by something a psychiatrist administered during the trial-and-error phase of treatment, it was not really mania. It was a mistake. What DSM-IV doesn’t do is remind doctors to apologize to these patients.

I didn’t know any of this when we were first dealing with Alex’s difficulties. And because we’d never been given a good explanation of what was happening to Alex, I continued to believe that he was not suffering from a real psychiatric illness. Maybe what he needed was a change of friends. Around the time that Alex’s outbursts worsened, he had stopped seeing a boy who had been his best friend for several years. I didn’t know why, and Alex wouldn’t explain. But he did explain to Psychiatrist No. 3, the one who had prescribed Ritalin. Apparently, the friend had been starting to spend less time with Alex and more time with another boy. Alex confronted his friend on the playground, and punched him. Other kids then descended upon Alex, surrounding him and hitting him. The pummeling didn’t hurt as much as the loneliness afterward, Alex told Psychiatrist No. 3. Alex said he’d lost several friends, one after the other. In every case, he said, he became angry and picked a fight. It frightened Alex. He didn’t know why it kept happening, or what to do about it. Until he’d talked to the psychiatrist, he hadn’t shared his fears with anyone. The psychiatrist asked Alex to make three wishes. “I’d like to be reborn, so I could start all over again,” Alex said. The psychiatrist waited; Alex was quiet. He didn’t use his two other wishes.

The day after this visit, Alex was agitated and depressed, and getting worse by the hour. Maybe it was time to think about putting Alex in the hospital, said Psychiatrist No. 3. He suggested we call 911 if things got any worse. I wanted to know why he wasn’t arranging for Alex’s possible admission to a hospital. What was the point of having psychiatric care if in an emergency the psychiatrist wasn’t involved? I didn’t want Alex sent to the county hospital, and that’s what would have happened if we’d called 911. Instead, we insisted that the psychiatrist see Alex again. He set up an emergency appointment two days later. The psychiatrist found him resistant to treatment, mistrustful, and hostile, but Alex did start talking. He said he’d felt depressed “all my life,” and now he felt even worse. The psychiatrist told us to stop the Ritalin, use the Ativan if necessary, and advised us again to call 911 if Alex seemed to present a danger to himself or anyone else.

Psychiatrist No. 3 was abandoning us. So I began calling everyone I could think of for help. A friend, a lawyer with a hospital in New York, put me in touch with a psychiatrist colleague who gave me the names of people he thought were among the best child psychiatrists in New York. I told him I was concerned that if Alex were hospitalized again, he would once again be discharged too soon, before he had made any progress. “You have to fight,” the psychiatrist told me. “Make it a risk-management issue. Deluge the hospital with the information showing he’s a risk. Put the hospital on notice.” The insurance company might have an arrangement in which any blame for inadequate care is shifted to the hospital, away from the insurance company, so the idea was to put pressure on the hospital. If they were worried about a malpractice suit, he said, they would fight with the insurance company to keep Alex there. “These people are not unprincipled,” he said. “They want to do the right thing”; but to make that happen, I would have to put pressure on them.

I called one of the psychiatrists he referred me to. The man was on his way out of town and could speak to me only briefly. He gave me the name of another psychiatrist, a friend of his who might help; I spoke to him. I called a friend at Johns Hopkins University, who said she could put me in touch with a child psychiatrist there, if I wanted to bring Alex to Baltimore. I called the headquarters of the National Alliance for the Mentally Ill, a leading patient advocacy group, and was referred to a local representative. I called the insurance company to find out what kind of coverage I had for Alex, and I was told that only fifteen days would be covered at the full rate. After that, the insurance company would pay 70 percent of the hospital costs; I would be responsible for hundreds of dollars in charges per day after the first fifteen days. Alex had already been hospitalized seven days; I had only eight more days before my out-of-pocket costs would begin to skyrocket.

Within a few days, the angry outbursts had become almost constant. Liz called Psychiatrist No. 3, and he increased the dosage of Ritalin. That night, Alex had what seemed to be a reaction to the increased dose of medication. He was very disturbed and wouldn’t respond to anything we said. He threatened suicide. We tried to get him to take a dose of Ativan, which was supposed to calm him in a crisis, but he wouldn’t take it.

I called the psychiatrist. A woman at his answering service said he was not available. I pleaded with her to call him, saying we had an emergency on our hands. The psychiatrist called back a few minutes later to say there was nothing he could do. I’d been told I would have to fight, and this seemed like the time to start. If anything happened to Alex, I said, I would make it very clear that the psychiatrist had been contacted and had refused to help. I called the police. They said all they could do was to take Alex to the county hospital. Alex slipped further out of control. He still refused to take the Ativan. An hour later, Psychiatrist No. 3 called back to say he was trying to find a hospital bed for Alex.

By the next morning, Psychiatrist No. 3 had arranged for Alex’s admission to the Westchester Division of the New York Hospital–Cornell Medical Center (now known as New York–Presbyterian) in White Plains, thirty miles north of New York City. He also made multiple calls to the insurance company, which demanded information on Alex’s condition from the hospital before agreeing to cover Alex’s treatment, then refused to precertify Alex’s treatment because the hospital had not provided enough information on him. This was no surprise, because no one at the hospital had seen Alex yet. But, if Alex was not precertified, we might find later that we would have to pay for the hospital ourselves. Our entire savings would not have covered more than a few days. The psychiatrist called the insurance company again and informed them that Alex presented a danger to others and possibly to himself. That did the trick. He called the hospital to let them know Alex was on his way.

When Alex woke up that morning, he paced from room to room, refusing to take any medication and threatening me and Liz. Without letting Alex see her, Liz quietly packed a small suitcase for him to take to the hospital. She put it in the storage area behind the backseat of the minivan we owned then. When we got the call in late morning that Alex had been approved for admission, we told him that we were taking him to see a new psychiatrist. After much arguing and cajoling, we persuaded him to get in the car. He sat in the back; Liz drove, and I sat in the front passenger seat. It was about a forty-five-minute ride to the hospital. Five minutes after we left the house, Alex turned to look behind the backseat, saw the suitcase, and figured out where we were headed. We were on I-95 when he reached for the door and said he was going to jump out of the car. There was no place to pull over. Alex looked as though he meant it. I undid my seat belt, climbed between the front seats, and fell on top of Alex, pinning him to the seat. He screamed, punched, and kicked, trying to push me off of him. I pressed harder. I was stronger than he was, but not by much. We stayed that way until we pulled up in front of the hospital. Liz opened the door. I lifted myself off Alex, whose energy was mostly spent, and stepped unsteadily out of the car. I was exhausted, physically and emotionally. I wondered whether Alex would ever trust me again.

It was Wednesday, May 8, 1996, less than two weeks after his discharge from the first hospital. In the interim, he’d had two visits with Psychiatrist No. 3, who had prescribed Ritalin. Psychiatrist No. 3 had no professional connection with the new hospital, so Alex would be starting treatment with yet another new psychiatrist. The hospital was housed in dark brick buildings spread across grassy, wooded hills, which gave it the look of a small college. We stepped into a paneled hallway and signed in at the admissions desk. We waited with Alex for a tense half hour before a hospital staff member escorted us to the teenage unit, where Alex would stay until a bed opened up on the children’s unit. On the way, he became increasingly agitated. “Take me home!” he yelled. Two aides ran up to him. He told them there was nothing wrong with him, that Liz and I were making up stories about what he’d done. They half-carried him to the quiet room and locked him inside. I could hear Alex banging against the door and the walls. The hospital staff assured us that they would take over and that Alex would be fine, and they pointed Liz and me toward the door. There was nothing we could do, no reason to stay. Get in the car and go home, they said. As we walked down a long empty corridor, Alex’s agonized screams echoed off the walls. I could hear them until we reached the end of the corridor and walked through a large double door. I can hear them still.

The hospital gave him fifty milligrams of Benadryl to put him to sleep. When he woke up, the hospital staff began to address its immediate goals for Alex. The first was to soothe his anger and the physical abuse, threats, and resistance to treatment that went along with it. That night, and on the nights to follow, he was scheduled for observation checks every fifteen minutes until morning. The next day, he was tearful but able to calm himself and take a shower in the morning. By the afternoon, he began to talk to some of the other children in the unit. We visited him later that day, and he became somewhat agitated again, requiring another fifty milligrams of Benadryl. The hospital psychiatrist and the staff discussed whether Alex might be suffering from a disruptive behavior disorder, but eventually settled on bipolar disorder as the admitting diagnosis. It was the first time anyone had suggested this as the cause of his suffering.

We visited Alex every day. Liz drove from New Jersey, and I took the train from New York. One afternoon, before visiting hours had begun, I spotted Alex outside in a small, sunny courtyard, a little monastic hideaway in the middle of the children’s unit. He was alone, at a small table, reading. I saw him through an open window, and called to him. He looked up and broke into a huge smile when he saw me. Oddly, it was in the otherwise difficult and sometimes tense circumstances of the hospital that we had some of our warmest exchanges. Alex’s worst emotional breaks, the episodes that took him to the hospital, were followed by what was beginning to be a pattern. He would protest violently upon arrival at the hospital, saying he didn’t belong here, that he was being unfairly punished for something that wasn’t his fault. Whatever had happened was the fault of his teachers, or his parents, or the police, or anyone but him. Then he would begin to realize that he was going to be in the hospital no matter how strongly he argued against it, and he would embrace the treatment program. Within a day or two, he would become not only a model patient, but a favorite of the hospital staff. His worst days, in other words, were followed by his best.

On these visits, I brought books to read to him. Sometimes he read to us. We brought him Chinese food or a pizza to share. One of the nicest things about visiting hours, for Alex, was the chance to eat something other than hospital food. And we would talk about what had been bothering him, about how therapy was going, about his favorites on the staff, about what video was scheduled for that evening. The hospital had provided a safe place for Alex to let go of the emotions that were turning him inside out. But two or three days was still too short a time for any treatment the hospital provided to take effect. Alex’s sudden improvement seemed to have more to do with him. He knew he was safe, he was in a highly structured, predictable environment, and he knew that if he behaved well he could go home soon. So he behaved well. I did not understand how simple, straightforward changes in Alex’s environment could produce such a remarkable improvement so quickly. I no longer needed convincing that Alex was indeed suffering from some sort of emotional illness, although no one seemed to know exactly what it was. His outbursts were not the actions of a bad kid, or a kid who needed punishment. They were out of his control, the consequence of some medical condition that he could not change and that was causing him enormous suffering. But if this was a true psychiatric illness, how could it be controlled so readily by a change in circumstances?

It had taken Alex about three days to feel this comfortable. He was doing well, but he was burning through the days allotted by the insurance company, and we still didn’t have a definitive diagnosis or a treatment plan. I was concerned that we would repeat what had happened with the first hospitalization, that Alex would seem fine, be released, and then descend into the same confusion and emotional distress that had plagued him for months. I called the hospital and explained my concern. What were they doing? I tried to tell them that each day was crucial, that Alex should be evaluated and should be seeing a psychiatrist regularly. The clock was ticking, I said, and I thought they should understand that.

Why was it so hard to explain this to them? Wasn’t this a situation they faced all the time? Hours, sometimes a whole day, would go by when it seemed that Alex would be doing nothing but participating in loosely organized group therapy sessions, playing games, making a feeble effort to look at his schoolwork, or eating and sleeping. Where was the intervention that would really help him? I made these concerns known as forcefully as I could. When I didn’t get much response, I tried calling the hospital’s executives to demand that more be done. Desperate, I told them I would make sure that they did what they were supposed to do, and that if they didn’t, I would resort to legal means to make certain that they did. It was an empty threat. I didn’t have the energy or the financial resources to pursue a legal claim, and I knew I probably wouldn’t have much of a case anyway. The simple truth was that I was angry. I wanted Alex to get better, and I was going to do whatever I could to make sure the hospital and its staff gave him all the help and attention he needed.

After the first few bright days at the hospital, Alex began to have problems. He was having trouble sleeping. It was the same problem he’d been having at home, sleeping erratically, sometimes staying awake all night and sleeping all day, or sleeping on and off at all hours. He did not seem well. His face was sallow. A nurse at the hospital noted that he had dark circles under his eyes. He was quiet, depressed, and apathetic, although he was able to avoid any violent outbursts. The hospital psychiatrist—for Alex, this was Psychiatrist No. 4—arranged for us to take Alex out on passes, for a couple of hours at a time, to the local mall to play video games and get something to eat. Although the psychiatrist didn’t tell us so at the time, the idea was to see whether the violent episodes recurred during the time away from the hospital. They didn’t. Whatever Alex’s condition in the hospital ward, he was fine when he was with us. As with the first hospitalization, it was tempting to conclude that Alex was magically improving, even though not much was being done at the hospital. They did put him on lithium, a mood stabilizer and one of the most common treatments for bipolar disorder. We were told that this would help ease the emotional swings that seemed to be driving Alex’s rage and depression.

On his sixth day in the hospital, Alex told the nurses that he felt like a failure, and that he had little hope of changing that. He no longer seemed violent, but he continued to need encouragement to interact with the other kids. He didn’t take care of himself. He refused to comb his hair or to take showers; he skipped meals and complained of insomnia. Although he seemed much improved during the time Liz and I spent with him, he was doing poorly during the day when we were not there. And he was due to be discharged the next day; after that came the sharp drop in reimbursement. A representative of the insurance company recommended that Alex be transferred to a part-time hospital program. She was not a psychiatrist, and, more important, she had never met Alex. Yet she was suggesting a change that would profoundly affect his medical care, and possibly, if his feelings of worthlessness and despair continued, his life. And what would be my recourse if Alex were discharged and something tragic occurred? There would be none. The insurance company was within its rights, according to its contract with my employer, to refuse additional care.

A social worker at the hospital gamely tried to find a part-time hospital program for Alex. There was no alternative. She talked to administrators at two such programs in New Jersey. Both said Alex was too young for their programs, and neither knew of any other in the state of New Jersey that could accommodate an eleven-year-old boy. The hospital prepared a tentative discharge plan. Alex would return home, and would return to the care of Psychiatrist No. 3, who had prescribed the Ritalin that appeared to have sent Alex into a tailspin. It didn’t seem like much of a plan to me, and I said so. I insisted that we could not return to the same psychiatrist. I had been favorably impressed by the psychiatrist at the hospital. It was an academic institution, affiliated with Cornell University’s medical school in New York City, and the staff seemed better educated and more aware of current psychiatric research and practice than the psychiatrists Alex had seen elsewhere. I asked whether Alex could continue to see the psychiatrist who was treating him at the hospital. No, the hospital staff did not provide outpatient care. There would be no exceptions. When the social worker told the insurance company that no part-time hospitalization program was available for Alex, the insurance company operative told the hospital that she would review the case and call with her decision the next day—the day Alex was scheduled to be discharged.

The night before the scheduled discharge, we went to the hospital for a parent-child group meeting, meant to be comforting and instructive. I found it tiresome. I had too much on my mind to be willing to show interest in the problems of others, and I was short on insights. Alex said he was having bad dreams at the hospital, dreams that scared him, but he didn’t say what they were. A nurse explained to Liz a point system that she could use with Alex at home, a way to reward good behavior with privileges, not unlike what was done in the hospital. The next morning, the insurance company called to say that it was granting Alex two more days at the hospital, and that it would review his case again then. The hospital staff found that Alex was still depressed, distant, and apathetic. He was still having trouble sleeping, and he didn’t have much of an appetite. For the first time, Alex was sent to participate in the children’s unit school program in the morning. In group therapy that afternoon, he said that in school he tried to be the class clown to impress his friends. He started acting silly in the group and tried to encourage the other patients to join him, but he was “easily redirected,” the hospital staff reported. “Underlying low self-esteem appears to be at the core of his difficulties,” according to a report by his psychiatrist, who observed him in the group setting. “He feels he is unable to make friends by just being himself,” and he “has a nihilistic view of the world.” The word “nihilistic” stayed with me. I could imagine an adult having a nihilistic view of the world, but I was taken aback to hear the word applied to my eleven-year-old boy, the child with the warm heart and easy smile.

We had a family meeting at the hospital the next morning. I was skeptical of the value of these sessions, and while I tried to be open and honest, I didn’t feel that they were contributing much to Alex’s treatment. I worried that they would open wounds and unleash a barrage of grievances. The children had long-standing gripes with one another and with Liz and me, and communication between Liz and me hadn’t improved. I was afraid that we would merely allow angry feelings to escape without time to resolve them. In the end, not much happened in the session. It had become distressingly clear to me that stress, anger, and anxiety surged through our family in a tangle of jagged nerves. Perhaps this had caused Alex’s difficulties; it had certainly contributed to them. It was also clear that this wouldn’t be easy to resolve. The family session led us nowhere.

The next morning, Alex was sent home.

Psychiatrist No. 3 was unwilling to take Alex back as a patient. Perhaps he felt he could do no more, or maybe he didn’t want to see me again, after I’d threatened legal action. The insurance company, in one brief empathetic gasp before Alex’s discharge, had given us the name of a psychiatrist to monitor Alex’s medication, and a psychologist to provide therapy.

Although the hospital psychiatrist had tentatively given Alex a diagnosis of bipolar disorder, neither he nor anyone else on the staff seemed sure that was correct. The new tally: four psychiatrists, none of whom Alex had seen for more than two or three visits, and his fifth drug, lithium. He had not been on any one medication for more than two weeks. Although he seemed better to Liz and me, he continued to experience periods of depression. There was no way to know whether the threats and the violent behavior at home and at school would return. We had exhausted our allotment of hospital days covered by the insurance company. If Alex were hospitalized again, we would be responsible for a substantial portion of the cost ourselves. We didn’t know what the future held. We knew only one thing: Alex was suffering. We all were.