MADMAN - John R. Suler, Ph.D. - copyright 1995
Chapter 7 - Edibles
"... Hello in there. Is anyone home?"I sprang to attention, as if jolted from a deep sleep. For a second I wasn't sure where I was. "Huh?"
"I asked if you wanted to go to lunch," Bob said carefully, measuring each word. "A bunch of us are heading down there."
"Yeah, sure!" I answered without thinking. "I'll be down in a minute."
"Are you all right? You've been sitting here for a while, just staring into that chart."
My head cleared. "Yeah, I'm O.K. Just a lot of work to do. You know how it is."
"I heard about your patient. I'm really sorry."
"It was a shock," I answered as I turned away and closed the chart. "I still can't believe it. Anyway, go ahead to the cafeteria. I'll catch up in a minute."
Bob awkwardly shifted his weight from one leg to the other, waiting for something else to happen. When it didn't, he turned to leave. "See you later."
I appreciated Bob's concern. He was genuinely warm and empathic, much more so than the other medical students. He treated his patients like people rather than specimens. He preferred talking to them over diagnosing and medicating. Although obviously well-educated, almost a full-fledged doctor in fact, he seemed a bit young and naive. Maybe that's what worked to his advantage. Some of the other med students had been bred by their training to feel rather grandiose and omnipotent - smarter, more important, just plain better than ordinary people. Our medicine-idealizing culture, driven by unconscious needs for an ultimate rescuer, helps elevate them to that exalted position. Then we turn around and get angry with them when they fail. It's all a defense against the fact that doctors, just like the rest of us, are helpless putty in the hands of life and death. The truth about being a medical student is that their training often lacks much glamor. They're at the bottom of the medical pecking order. They're often treated like second class citizens.
I suddenly noticed a twinge of pain in my throat, as if something sharp was stuck there. I swallowed hard. Yes, definitely a sore spot, just below my left ear. The first warning sign. Damn! I couldn't afford to get sick. I had too much work to do. As I swung my knapsack over my shoulder, its contents rattled around inside. Hoping to avoid any of the staff, I hurried off the unit. Just outside the door Phil was poking his screw-driver into what looked like a partially dismantled lock.
"Sorry to hear about your patient," he said as I passed by.
Did everyone in the entire hospital already know? I tried to act casual. "I guess Marion told you about it."
"No," he answered, still fidgeting with the gadget in his hand. "I heard some of the nurses talking about it."
"I was very surprised to find out about it," I said flatly. "It was a shock."
He pointed the lock at me. "It's like I said. You never can predict what's going to happen in there. It's like the weather."
I felt irritated. "Yeah, right Phil. See you later."
I detoured to the men's room on the way to the elevator. At the urinal I read the graffiti on the wall - not that I needed to actually read those pearls of wisdom. After spending what must amount to hours of time standing in that one spot, I had unwillingly committed to memory every word, scratch, and discoloration on those tiles.
"Jesus Saves."
"She blinded me with science."
"Look up... Look down, the joke is in your hands!"
When I finished, I realized I was not finished. So little time, so much to do. In the stall the seat was cold. Perhaps I was its first occupant of the day. I sifted through the graffiti on the dividers, looking for some new inscription to take my mind off things. There was more literature here than above the urinals - I guess people felt freer in this hidden place to really let out all the crap - but it was the same old pornographic and bigoted comments. It's amazing how even the bathroom stalls in institutions of higher learning draw out the dregs in human nature. Freud was right: sex and aggression lurk right below the surface. Sitting here on this earthly throne, secure behind metal walls, otherwise civilized fellows allowed themselves to ventilate these inner tensions. In more ways than one, they tried to purge the private toxins that could not be metabolized.
I felt drained. With my eyes closed I leaned forward and dropped my head between my knees. My spine slowly stretched out, relaxing my entire body. I also tried to ease my brain, but my mind insisted on grasping at a flurry of thoughts. After a minute or so, I opened my eyes. There, on the round surface of the toilet, was some faded writing. The tiny letters were scratched in and inverted to accommodate an upside down reader, like my- self. It read: "While alive, be a dead man."
I laughed out loud. Surely some patient had escaped from the unit and engraved his psychosis here. If that was true, how would he do it? Patients are not permitted sharp objects. I imagined some poor schizophrenic huddled over the toilet, desperately trying to record his delusions with a house key. A tormented Moses.
The bathroom door banged. Someone had entered. I listened. At first there was silence, then the soap dispenser pumping, rushing water, the ruffling of paper towels. Then silence again. I waited. Had he left?
Time ran out. I gave the roll of toilet paper a spin and prepared myself to leave. I took a deep breath as I zipped up and swung open the metal door.
I knew it! Standing in front of the mirror, carefully adjusting his tie, was Dr. Stein, Director of Psychiatry and internationally famous shrink. For a moment I thought of quietly slithering out, but that was impossible without being detected. I crossed my fingers. "Hello, Dr. Stein," I said meekly, hoping he wouldn't take notice of my identity. With his neck remarkably straight, he turned his head slightly in my direction. I was hoping for a smile or a friendly nod, but received none. Without his aristocratic expression changing one iota, he returned his gaze to the mirror. "Hello Dr. Holden," he said.
His odd accent on the word "doctor" made me uncomfortable. Technically speaking, I had finished my dissertation and was therefore entitled to so prefix my name. However, in an institution filled with MD's, people get very fussy about the definition of a "real" doctor. Then again, maybe I was just paranoid. After all, any formal title just doesn't seem to hold much water among toilet bowls and urinals. Here, regardless of status, we're all the same basic biological creature.
Having acknowledged his existence, thereby fulfilling the rudiments of etiquette, I tried to make my escape. As I reached for the door he spoke in a clear voice that reverberated off the tile walls. "I heard about your patient."
Oh shit! I thought. Another two seconds and I would have been long gone. I knew it was too good to be true.
"You mean about Elizabeth Baso?"
"I mean the patient whom you discharged - the one who died this morning."
"Yeah. It was a real shock to me. I still can't - "
"I believe we should talk about this during a staff meeting," he interrupted, still examining his tie in the mirror. "It's a rather ... shall we say ... unusual event."
In my head flashed an image of Stein hanging from the light fixture by his silk Bill Blass. "I think that's a good idea. I'd like to talk to the staff about it."
When he didn't answer, I assumed our tryst was over. The full interrogation would come later. Feeling shaken, I left. Although fogged in by my ever-expanding ruminations, I managed to find my way to the elevator. I rapped the "Down" button with my knuckle, and waited.
Even Stein knew. I could just imagine the gossip that was spreading. Suicide. Premature discharge. Poor clinical judgment. Creeping words that poison reputations like indigestible cancer. But it could not have been suicide. The depression had lifted by the time she left the unit. She definitely had improved... And besides, I wasn't the only one responsible for her discharge. The whole team made the decision. Even the attending physician must interview the patient and consent to the release... Look at me, defending myself as if I was already guilty!
I remembered Elizabeth's face just before she left. She smiled. Her dark eyes had lost their dull, languid stare. They connected with mine. "Thank you so much," she said. I felt touched.
My stomach sank. "It wasn't suicide," I mumbled, but I didn't fully believe myself.
"Going down?"
A smiling physician held his finger on the button while he beckoned me into the elevator. He smelled like formaldehyde and had a large plastic bag folded under his arm. As I thanked him and stepped inside, his grin widened. I quickly glanced at his plastic name tag. Wonderful! Of all the people in the world, I wind up in the elevator with Dr. Theodore Gilbert, the giddy coroner. Leaning my head against the wall behind me, I imagined the day when I would look back on all this and laugh. I imagined what my biographer would write:
Holden experienced his internship as a trying period in his professional development. The tidy theories he learned as a graduate student crumbled under the pressures of clinical practice. Even the noblest of conceptual models foundered in a strong undercurrent of uncertainty. Psychology, the supposed science of predicting behavior, lacked precision. Traditional theories could not forecast all out- comes, not in real life circumstances and not even in the sterile confines of strict experimentation. These frustrations with the limits of conventional ideas catalyzed Holden's search for a more comprehensive explanatory paradigm.
Just a high-falutin' way of saying that I'm totally confused.
My nose dripped. "Damn!" I thought as I sniffed up the dribble. This was the sure sign of an impending cold. I knew that within half a day my whole head would clog, as if pumped full of oil sludge.
The elevator hit the ground floor and the doors popped open. Gilbert smiled as he gestured towards the way out. "After you," he said gleefully.
"Thank you," I answered politely. I was glad to get out of the elevator. He made me nervous.
The cafeteria was packed, which surprised me since it was still a bit early for lunch. Many people wore those cardboard name-tags inserted into plastic holders. The hospital probably was sponsoring some medical conference which broke early for some eats.
Someone was standing behind me. I spun around. It was Gilbert, looking past me, grinning. He had spotted some friends at a table across the room and walked past me to greet them. Good lord! A convention for coroners!
I zig-zagged through the crowd towards the food counters. Considering we had a thousand years of higher education among us, we were rather primitive in our jostling for position. I accidentally elbowed someone in the stomach. In return, someone stepped on my foot. Food brings out the worst in people. Ask any bulimic.
A women was standing close in front of me. At first I paid no attention, but she swayed backwards slightly, almost touching me. A snap of static electric charge jumped from her wool sweater onto my arm. Suddenly I felt keenly aware of her presence. I could smell the fragrance of her hair, sense the curves of her body. Another Being, enticingly the same but also different - so close, but so very far. I tried to redirect my thoughts towards the food, but she pulled at my attention. She knew. I could sense her presence so acutely because she sensed mine. It was almost - intimate. Maybe it was just my imagination, or wishful thinking. But instinct told me otherwise.
Slowly, she turned her head to look over her shoulder, right into my eyes. My insides froze. If there was any psychological gap between us, it collapsed. Her eyes were large and deep brown. I could swear I saw myself in them, looking with her at myself.
The crowd moved. The bubble popped. She disappeared into a group of tall men wearing lab coats. Disoriented, I found myself shuffled forward towards the food counter. Curiously unaffected by the chaos before her, the kitchen aid with rotten teeth waved her ladle at me. "What'd ya like, sir?"
I tried to focus myself and quickly surveyed the options: liver floating in brown liquid, carrots and peas, greasy sausages, something unidentifiable, and ... spaghetti. Eureka! That seemed safe enough.
"I'll take the spaghetti," I said confidently. As if anticipating my response, she had already begun preparing my plate.
"Red Sauce?"
"Yes, please."
She lifted the cover off the tureen and dipped in her ladle. The sauce was rather loose, and more brown than red - no doubt close kin to the fluid drowning the liver. Holding a cup of hot coffee in one hand and a plate of sloppy spaghetti in the other, I parted the crowd like Moses slicing the Red Sea with his staff. "Why don't you use a tray?" someone grumbled. Watch out, I thought, or I'll use your shirt. When I reached a clearing, I looked around the cafeteria for that woman, but I couldn't see her. Near the windows some nurses and residents from the inpatient unit were eating at a round table. Somewhat hesitantly, I walked over to them and carefully laid down my lunch. A large chunk was broken off the edge of the table, which was going to be uncomfortable for my elbows. But there were no other places to sit. Barb smiled at me as I sat down next to her. The others were pretending to listen to Ron's monologue.
"... It's really a very straightforward process. First, you have to assess the patient's symptoms. You look for affective disturbances, motor disturbances, hallucinations, delusions, or other evidence of a thought disorder. The mental status exam will give you some of the data you need. You determine how the symptoms have affected the patient's level of functioning. Then you do a thorough history, and you pay special attention to the evidence of mental disorders in the family and relatives. That's always a dead give-away. The rest is easy. If you've done a careful assessment, you should have all the data you need to make an accurate diagnosis. Sure, it may take some additional information to fine-tune the diagnosis, but you should definitely be able to apply the major diagnostic categories - whether it's paranoid, disorganized, or catatonic schizophrenia, a unipolar or bipolar disorder, major depressive episode, senile dementia, drug-induced psychosis, ... or whatever."
"Depression IS unipolar disorder," I said to my spaghetti.
Ron pricked his ears and briefly darted his eyes towards me - but he didn't say anything in reply. With even more vigor he pushed ahead with his soliloquy. Eager for a receptive ear, he aimed his words at Bob. Med students are convenient targets for hot air.
"If you carefully read the DSM, you should be able to classify any mental disorder. It's a very comprehensive and accurate manual - much better than the earlier diagnostic systems, mostly because it includes both inclusion and exclusion criteria, which increases interjudge agreement. In fact, the DSM categories show high reliability and validity. I was just reading an article by Goldman in AJP, in the October issue, and he found correlations over .90 between DSM diagnoses of schizophrenia and independently obtained criterions involving various etiological and predictive variables."
Bob struggled to hold back a yawn, but Ron's verbiage seemed to make Carole's red hair stand up on end and her face glow until the freckles almost disappeared. Obnoxious residents always irritated her. She was an unusual combination of modesty, confidence, and cool intelligence. As head nurse, she kept the doctors in line, though they would never admit it. They feared not only her assertiveness, but also her cognitive prowess. A month ago they all quietly panicked when they heard through the grapevine that she had taken the tests to join MENSA and passed with high honors. There were also rumors that she was a math buff who could hold her own with even academicians. She never flaunted her intellectual and interpersonal skills, and usually was quite low-key. But when she or any of her nurses were mistreated in any way, she could strike back like a tigress. At the moment, however, it was more a matter of her swatting a buzzing insect that was making a nuisance of itself. Tolerating the pomposity of medical directors is one thing, but swallowing it from an insolent resident is another.
"Wait a minute, Ron," she said crisply. Her nose wrinkled. "When you talk about diagnosing you make it sound like that's the epitome of psychiatry. Simply slapping a label onto someone doesn't in itself make them get better. And sometimes the label can do more harm than good. Once you start throwing around terms like 'schizophrenia,' they may stick to people forever. No one wants to be black-balled as a mental patient."
The swat reddened Ron's cheeks. With tension in his voice, he waved his fork in the air and retaliated. "Of course, we want to avoid the bias created by diagnostic labels. But coming up with a coherent treatment plan is dependent on an accurate diagnosis."
"I remember ...," Sheikh interjected between the titans, "I remember in medical school in Pakistan we discussed these issues. We did not use DSM, but instead international system. Making psychiatric diagnosis is very difficult, more ambiguous than other medical fields. And this is true of treatment also. Working with patients is a very delicious matter."
Momentarily baffled by Sheikh's non sequitur, we all looked at each other.
"You mean... a very delicate matter?" Carol said.
We all laughed.
"Yes, yes," Sheikh replied self-consciously, but with a giggle. "A very delicate matter. My apologies."
"You know what happened to me the other day?" Bob interjected. "I was in the outpatient department seeing one of my patients. You know how the rooms are there - crowded together with paper thin walls. Well, I'm working with this neurotic woman who has anxiety attacks, and she's talking about how she doesn't want to be in therapy, how she thinks hospitals are only for sick or crazy people. My supervisor said that she's really afraid of being insane herself, she's scared that she might be the one who needs to be hospitalized. So I'm trying to explain to her that not everyone who comes for therapy is sick or crazy, that even normal people sometimes benefit from professional help. All of a sudden we hear someone screaming in the room next to us, 'Why are you doing this to me! Leave me alone! Let me out of here!' Well, my patient's face turned white. I thought she was going to pass out! Talk about poor timing!"
Everyone laughed, except Ron who was trying hard to think of something to say. He felt deflated because he wasn't holding the center of attention. People like Ron need to be heard and admired in order to feel alive and important. As children they desperately tried to make Mom and Dad listen, but they never quite got enough - or maybe they got too much.
Carol beat him to the punch. "When I worked at Hillside, we had a suite of rooms we used to see patients. All of the staff shared the suite, so when we were using a room we would put a 'Do Not Disturb' sign on the door to let the other people know it was occupied. To prevent people from interrupting your session, that system worked fine. The only problem was that people sometimes forgot to take the sign off the door when they were finished with the room. If a door was closed and had a sign on it, you could never be sure if the room was occupied or empty. You had to develop all sorts of strategies to determine whether it was vacant, like go back to the main desk and check the schedule book, or put your ear to the door, or look for light under the door. Well, I was working with this patient, a paranoid guy who thought the KGB was after him. He really believed they had him under constant surveillance, with phone taps, tails, the whole bit. In therapy I was working on trying to improve his reality testing, you know, trying to help him see that maybe his delusions were really projections of his own feelings about himself.... Anyway, one day as our session was ending, I walk him to the door, he opens it - and there in the foyer, right in front of us, is the new psychiatry resident, a Russian-looking guy with a bushy beard and three piece suit. And he's on his hands and knees peering under our door! We almost tripped over him! I talked myself blue in the face trying to explain to my patient who that person was and what he was really doing. To say the least, my patient had a real hard time giving up his paranoid beliefs."
"I've got a better one than that," Ron blurted out, no longer able to control himself. "You know how we sometimes have to call security to come up to the unit to help us control a violent patient - but the hospital policy states that they can't bring any guns with them. So because my office is right next to the unit, I told them that they could put their weapons in my filing cabinet before they come onto the unit. So, one day, I doing therapy with this paranoid patient. Suddenly, right in the middle of the session, the door flies open and these two huge security men come running in with their guns drawn! Can you beat that?"
"You mean you told them to put the guns into your office while you were seeing this patient?" Sheikh asked curiously.
"No! No! They were on their way to the unit. There was an emergency there. But they first had to come into my office to put their guns away."
"My god! That's awful!" Carol said. "A paranoid's worst nightmare come true. Maybe you shouldn't let security put their guns in your office. It's not right that they intrude on your patients like that."
"I'll say," I mumbled through the pasta hanging out of my mouth.
Ron again glanced at me, but directed his response to Carol. "No, it's not really a problem. They only interrupted us for a second. And besides, it hasn't happened often. In fact, that was the only time they actually interrupted one of my sessions."
"But if you don't tell security to put their guns somewhere else," Carol said, "it could happen again. We should take every precaution we can to protect the patient's right to confidentiality."
"But the sessions ARE confidential. I don't talk to anyone about the specifics of my cases, except for my supervisor. Security only popped into that session for a minute. They don't know who the patient is or what we were talking about."
"I give up," Carol murmured. She looked at her watch. "Lunch time is over for me. I have to get back to the unit. See you all back at the fort." She stood up, but before leaving reached under her chair for a bag and held it out towards Ron. "Do you mind, Ron, if I leave my sweat socks in your office? I went running before lunch, and I prefer not to bring them onto the unit."
For a moment, silence. Then Sheikh slapped his stomach, rolled back his head, and let out a gurgling chuckle that made his shoulders shudder and his bushy black eyebrows twitch. Everyone joined in the laughter, except Ron who tilted his head sideways like a quizzical terrier.
"Only kidding, Ron," Carol said as she walked away.
When the laughter subsided, Sheikh lightly patted Ron on the back. "You must be careful with her, my friend. Otherwise, how do you say it, you will open your mouth and change your shoes."
"Open your mouth to change feet," Ron darted back. "Listen, what's the big deal about this anyhow? I think people worry too much about confidentiality. We're working in a university medical center here. It's the whole hospital and it's staff that are responsible for a patient. We can't get overly preoccupied about one therapist maintaining the confidentiality of one patient - even in outpatient psychotherapy. It's not practical, and it may not even be in the patient's best interests."
After a brief silence, Bob looked at me. "Tom, what do you think?"
Caught by surprise, I almost choked on a strand of spaghetti. "What do I think of what?" I sputtered between two coughs.
"What do you think about confidentiality in psychotherapy?" he answered.
"Well," I said, trying to clear my throat, "I've been trained mostly in psychoanalytic psychotherapy - and in that kind of therapy confidentiality is extremely important. In order for the person to really open up and talk about their most private problems, they have to trust that you won't be telling anyone else."
"But you're assuming that psychoanalysis works," Ron quickly replied. "I think research has shown this is questionable. If you're going to administer any kind of psychological treatment, you had better go with the behavioral techniques that have been validated by experimental research. Of course, the preferred treatment, in terms of effectiveness, would be psychopharmacological rather than psychological."
Them's fightin' words. If thoughts could kill, my mind would have reduced Ron to a pile of smoldering protoplasm. But I had to keep my cool. He was throwing me a hook with live bait. But don't bite!
"I guess I don't agree with physiological reductionism," I reluctantly mumbled between the strands of spaghetti hanging from my mouth.
"What?"
"Reductionism, you know, assuming that physiology will explain all psychological events."
"That's right. All mental disorders are caused by some biochemical dysfunction. The evidence is clear for schizophrenia, and the affective disorders, like depression and manic-depression."
"Isn't it possible that some problems are purely psychological in origin, that physiology has nothing to do with it?"
"No," Ron pronounced. "Everything is ultimately explained by biochemical changes in the brain and nervous system. And we're learning more and more about this as science advances."
I stared down at my plate of spaghetti. I didn't want to get into this with Ron. I didn't want to lose my head. Instead, to calm myself down, I imagined lying on a beach, with the blue sky and sunshine above, the sound of the waves, my toes wiggling in the warm sand.
"You see," Ron's voice continued, "even the so-called neurosis are biologically caused - like anxiety attacks and obsessive-compulsive disorders. Psychoanalysts claimed these problems were purely psychological, but the fact that they've been unsuccessful in treating them only shows that the true cause is biological. Someday we will discover the underlying biochemical problem and then be able to treat it with drugs - by altering the brain biochemically, or by some other physiological intervention."
In my imagination, a little boy was standing next to my beach blanket, kicking sand into my face. I shook my finger at him and gave him a scolding look, but he didn't budge. "Well, Ron, how about this," I said. "Let's say you have a computer program that won't run. It bombs on you. How would you fix it?"
"Well, there must be a mistake in the program somewhere. The error message should tell you the where where the program hung up. You'd have to patch it somehow so it would run correctly."
"But you wouldn't you go into the computer's hardware with a screwdriver or a knife to cut and paste the circuits? Or poor chemicals in it to fix the problem."
"Of course not."
"Right. Because there's nothing wrong with the hardware. If you tried to change it, you'd be missing the boat, and you'd probably make the problem even worse.The real problem is with the software, the programing. Then couldn't the same be true of neurosis? The problem isn't in the brain structure, so we don't need medications or psychosurgery. The problem is in the software, in the psychological programming, so to speak. That's the level you have to work at. And we call that work psychotherapy."
"No. In the case of neurosis, we just don't know yet what the neurological causes are. They're probably very subtle biochemical abnormalities that we can't detect. It's just a matter of time before research finds them."
So much for the Socratic method. Apparent there's little correlation between IQ and narrow-mindedness. My frustration mounting, I again looked down at the spaghetti and tried to return to the soothing comforts of my beach.
"This is most interesting," Sheikh said. "I have noticed American psychiatry does much emphasize the physiological theories. And this seems to lead to much emphasis on technological advances."
"That's because it's the state of the art," Ron replied enthusiastically. "To understand behavior you have to understand the brain. And for that we need neurophysiology, biochemistry, and even physics - especially physics. After all, it resulted in catscans and laser microsurgery. In a few more decades we'll have even more sophisticated instruments that will let us assess and modify the fine details of the nervous system. That's when we'll start eliminating mental illness."
The boy next to my beach blanket somehow had gone through a dramatic metamorphosis. Now he was a big, red crab. He was poking and pinching me. "O.K., Ron. I personally don't believe we'll ever be able to eliminate mental illness with electronic gadgets, no matter how sophisticated they are - but let's say that someday we do have these instruments you're talking about. If we could eliminate someone's neurosis by altering their brain, could we also use it to correct character disorders."
"Sure."
"But most psychologists and psychologists agree that character disorders are deeply ingrained personality styles. They're the result of early childhood development. They're learned, just like many aspects of normal personality - unless you think that normal personality traits are also biologically determined. If we use these instruments to alter character disorders, then we could also use them to alter normal personalities.We could even take newborn children, stick their heads into the electronic gizmo, and give them a prepackaged personality. One out of every ten will be shy, one intelligent, one artist, one scientist - no, make that three, of course - we need lots of scientists. On the other hand, maybe we won't even bother making people different. We'll make them all the same to simplify things, in an Orwellian sort of way. Who's going to make those kinds of decisions, Ron? Scientists? The government?"
It was happening. I was losing control. I buried my head and torso into the beach, to hide, to soothe my brain in the cool depths of the sand. Above me, the RonCrab's voice was still clicking and clacking as it's claws gnawed at my feet. "I don't know it would ever come to that. In any case, it's not up to scientists to make such decisions. The same kind of problems pop up with abortion and euthanasia. Scientists can't say when life really begins and ends. They can't say when or even if it's right to terminate a pregnancy, or to pull the plug on someone who's brain-dead. They just discover the laws of nature, the solid facts of the universe."
With that remark, I catapulted myself out of the sand, layed my hands onto a nearby beach umbrella, and yanked it up out of the ground. Standing above the RonCrab, I aimed the sharp metal point of the umbrella at the center of its body.
"But that's the whole problem," I said. "Science is too busy discovering facts and too ignorant of the ethical consequences of its discoveries. And what's worse, many scientists don't even respect the philosophical thinkers who ARE trying to make sense out of this crazy technological age of ours. Take Nietzsche, for example. He predicted that our modern age of science and technology would bring about the collapse of all sense of purpose and meaning in our world. Isn't that scary? He's also a good example of this debate about illness being psychological or biological. It's clear, historically, that he suffered from the advanced stages of syphilis and for the last years of his life was schizophrenic as a result of the infection in his brain. He was as crazy as a loon. Biologically caused insanity, right? Well, I heard this philosopher who suggested that whether or not it was biologically caused was irrelevant - that the most important point was that Nietzsche WILLED his insanity. What do you make of that Ron?"
He had no reply.
"Can I take those trays?" A hand reached over my shoulder and pointed at our table. A kitchen aid was standing behind me. Surprised, I shifted sideways away from his arm. It struck me that there was something unusual about his hand; half of his index finger was missing.
"Sure. I'll get them for you," Sheikh replied as he gathered up the trays. While he waited, the aid quickly picked his nose with his deformed digit. It looked like a whole finger had disappeared up his nostril and poked into his brain.
"Bob, how was you salad?" Barb asked.
"It was O.K. The lettuce was a little soggy, though."
"I guess they didn't let it dry off after they washed it."
My appetite had vanished. There was something unpleasantly gritty in my spaghetti - something a lot like.... sand. I poked my fork into the plate. The intertwining noodles and patches of sauce formed an intricate, complex pattern. The overall impression was a face with a slightly bewildered expression.
For a while, we were all quiet. Clasping his hands beneath his chin, Sheikh put his elbows on the table and leaned towards me. "I heard about your patient who was discharged," he said with genuine concern. "Perhaps you would like to talk about this - if you wish."
"No, I don't mind," I said as I leaned towards him. The broken edge of the table scraped my forearm. I sat back again. "It was Elizabeth Baso, the depressed patient I was working with. We discharged her yesterday. She seemed fine - sleeping O.K., good affect, optimistic. This morning she walked her kids down to the bus stop. When they drove away, she walked out into the street and was struck dead by a mail truck. When the police found out she had just been treated in a hospital for depression, they suspected suicide."
"Were there any witnesses?"
"Two other people, both neighbors."
"Did they notice anything unusual about her?"
"One of them said she looked good, much better than a few weeks ago. The other one said she looked weird. I don't know what she meant by that. I guess if you've just been released from a psychiatric hospital, some people are going to think you look weird, even when you're fine."
"I can't believe she would hurt herself," Barb said as she searched our faces. "She was such a good person."
"Did she look both ways before crossing, or that sort of thing?" Bob asked.
"I don't know. The women didn't say, I guess. They just said Elizabeth was standing there at the corner, and then walked out into the traffic."
"It sounds like depersonalization," Ron declared. "She didn't know what she was doing or where she was. She was in a fog. She might have been decompensating."
I could feel my irritation building again. "I doubt it Ron. She never showed any signs of decompensation while she was here. There was no thought disorder, no psychotic symptoms at all. And by the time she left her depression had lifted."
"The signs of decompensation can be subtle. You can sometimes miss them if you don't do a thorough assessment."
My fists tightened. "My assessment of this person WAS thorough, Ron!"
"Oh, I'm not saying that it wasn't. I'm just saying that in general you have to be careful about evaluating someone before you discharge them."
"I'm going to get some ice cream," Barb interjected with a nervous smile. "Does anyone else want some?"
I shook my head. "Listen, Ron. We did a very careful assessment of this person. In addition to the intake, we administered a battery of psychological tests when she was admitted - we even readministered some of the tests just before she was discharged. There were no signs of decompensation before or after her treatment. The tests obviously indicated depression when she got here, but at the time of discharge there was much less evidence of it - and all of the indices for suicide were negative."
"What tests did you administer?"
"Our standard battery - the MMPI, Rorschach, WAIS, TAT, and Bender."
"Hm."
"Hm?" I echoed.
"I guess its good that the test results were favorable. But then there are limits to psychological testing."
"I don't follow you, Ron."
"Well, tests like the MMPI do seem to be somewhat valid. There's some research to support it. But there's very little evidence to suggest that projective tests like the Rorschach are useful. In fact, most of the research indicates that inkblot tests are not very useful."
Just what I needed - a fledgling psychiatrist, who never received training in psychological testing and probably never laid eyes on an inkblot, lecturing me about the Rorschach. I wanted to dip his face into ink and use it to print my own inkblot.
"Actually, Ron, there is a lot of current research being done to support the Rorschach. Besides, my opinion is that so-called scientific research is not even important for validating the use of some psychological tests. A skilled clinician with years of experience can do diagnostic and predictive miracles with the Rorschach. I once saw a psychologist use it to predict that a patient would attempt suicide - and that she would try to do it by hanging herself. Mind you, there was no specific mention of suicide or even death in her Rorschach responses. Later that day the staff found a heavy rope under her mattress."
Ron retaliated. "There are much more sophisticated ways of assessing psychiatric disorders. Looking at inkblots is simply childish."
I sighed as I poked my fork between the spaghetti man's eyes. "Well, Ron. There's one other way to prove to you that the Rorschach is a valid test. How 'bout we administer it to you? We could do it this afternoon."
Ron's pupils bounced around like pinballs. "I'm too busy."
I could have sworn I heard the sound of a shell crack.