Wednesday, July 6, 2011

Doing better can create danger!

Intense Insight

While many people with serious mental illness have no idea that they are ill, it can still be difficult for them to deny the evidence of their illness. Surrounded by poverty, ill health, repeated incarcerations and hospitalizations it is impossible to not know that something is wrong.  There can be moments of extraordinary clarity that can be as frightening and dangerous as the worst symptoms.  Getting the right kind of help during this time is a challenge for the patient and the helper.

The Story

I stood there in the harsh light of the morgue, walking around the body staring at the face.  It looked somewhat familiar, but distorted in ways that made it difficult to discern.  He had jumped from one of the higher bridges, almost 17 stories, nearly 170 feet into the gorge.  When he’d landed, he’d  hit his head, and the bruising, swelling and missing teeth combined with almost 24 hours in the water had altered his appearance in nightmarish ways. He looked shockingly like a Halloween pumpkin ready for display.   He’d jumped in the early evening and only one person had seen him.  If not for her, we may have never known what happened. He might have gone over the falls and into the lake without anyone knowing. As it was, he’d ended up in a small deep pool a half mile downstream.  A uniformed cop with a long pole had found him.
  “Could you help me roll him,” the investigator asked, “I want to see if there is anything in his back pockets.”   I could feel the cold through the rubber gloves.  I grabbed a belt loop on the jeans with my right hand and pushed hard with my left on his shoulders.  We tipped him on his side and the second investigator carefully searched the pockets. We returned the body to its prone position and started to remove the clothing and bag it.  It was driving me crazy! Who was it! I knew I knew him!  He was a Southeast Asian or Hispanic male, early thirties to early forties without a damn bit of ID on him.  When he was naked I left the room.  Someone knew this man, loved this man, and he was dead and they didn’t know it.  
I went back to the clinic and talked to my colleagues.  They were stumped.  I went to the records department to try and jar my memory. Our records room was a big square room with tall metal shelves filled with three ring binders with names on the side. I started with the A’s going from top to bottom, left to right, walking slowly along the shelves.  By the time I got to the end of the open cases, I was sure we weren’t currently treating him. I began to look at the names of the closed case binders and got to the second shelf and realized I’d found my answer. I pulled out the binder and started reading the notes.
Doug was his Americanized name.  He wasn’t born in the US, but had been raised here.  His parents had attended Cornell as grad students and separated when he was about seven. His dad returned to Asia and his mom stayed, starting a small home based business that thrived. She and Doug moved in with a widowed man who also had a son a few years younger than Doug. The family was happy until Doug started to have psychotic symptoms just after high school graduation.  Mostly he heard voices that called him names or cursed at him. He’d respond to the voices by yelling and cursing back.   Sometimes he would break things in the house or imagine his step- brother was against him and make vocal threats against him.  His actions made it impossible to stay in the family home, so he moved through a series of crummy apartments and rooms.  He’d work washing dishes or shoveling snow or cutting grass.  His threatening statements caused a string of hospitalizations that would be followed by periods of calm. Then he would stop taking medications, start smoking pot and the process would begin again.
Each time he was hospitalized, he would be referred to our clinic for outpatient treatment upon discharge.  He had little insight as to his illness, but he hated to be hospitalized and often the focus of treatment was our encouraging him to take the medication to avoid the hospital.  Another consequence of his becoming stable was the onset of depression.   His depression was the result of this clear, unobstructed view of his life, at least as he saw it.  He was a loser, almost thirty and nothing good happening.  He’d tell the psychiatrist, “Everybody I know has a better life than I do.  Everybody I went to school with is a success. They have good jobs, wives and kids, houses and cars and I’ve got shit.”  The doctor, of course explained that it was not true, not “everybody” he went to high school with was doing great.  In fact we knew some, both personally and professionally, that were not doing well at all.
Eighteen months earlier Doug’s father had come from Pakistan and after consulting with Doug’s mom took him home with him.  We closed his case and went on treating the other five hundred and sixty patients.  Doug had returned with his dad six weeks ago.  His father had made an appointment with the doctor for a consultation.   Although not uncommon, a parent requesting a doctor visit without the son, who was the patient, made me wonder, so I decided to sit in.  “For almost a year now, I have been treating him.”  Doug’s father began.  “My cousin is a doctor and he has prescribed the very same medicines he was given here in the United States.  Each day I have crushed up this medicine and placed it in his food. I have never seen him doing better.  If you would just continue to prescribe this medicine, his mother has agreed to continue to put it in his food.”  “Does he know he is taking the medication?” the doctor asked.  The father replied, “Of course not, he would stop taking it like he always does. This is working so much better and all we need is the prescriptions and we’ll take full responsibility.”   He left our office sad and dejected and not fully understanding why we could not and would not participate in his plan of deception.  He went back to Pakistan telling his wife he would send the medications.
Doug’s mom had called about a month ago, after the dad left.  “I understand why you couldn’t do it, but his dad is a stubborn guy.   Doug is really doing great.  He’s applied to community college and says he will make an appointment with you guys.  He’s got some money from his granddad and has rented an apartment in college town. I’ll give you the address.”   I went to see him at one of the newer apartment houses, filled with Cornell students.  “Nice place,” I remarked as I entered his apartment.  It was easily the nicest apartment he’d lived in since he’d left home. It was neat and well cared for. He looked good; clean clothes, nice haircut. He said, “I thought since I was going to college, even community college, I’d try to live the part.”  We talked for a little while and I set up an appointment for him and left.  He never kept the appointment and when I returned he was not there or did not answer the door.   I’d spoken briefly to his mom and she said he was still doing Ok, but seemed stressed. “I’ll try to get him to see you.”
I put the binder back and walked over to the police department. When I got to investigations I looked at the pictures from the morgue. I knew the answer, but had to confirm my suspicions.  It was him!  I went with the investigator to Doug’s apartment and we got the landlord to let us in.  The smell of rotting food in styrofoam greeted us. The place was a mess. No note or indication of his thoughts.  I called his mom. “Have you seen Doug?”  I asked.  “No we haven’t seen him for a week.  He had dinner with us Sunday and he was really depressed.  Being around all those successful kids wasn’t a good idea. He just kept saying, I’ll never catch up.”  I took a deep breath and said, “Are you going to be home for a while, I want to stop by and talk to you?”
The Lieutenant and I went to see her.  He told her there were other means of identification they were pursuing; that the remains were unpleasant to view.  “No mother should have to see their child like that,” he said to me as she entered the morgue.


  1. This is really sad. I didn't know that getting better could cause such problems

  2. Yeah, I know someone who really had problems when he got stable. I think he was bi-polar. Ut was like he had to deal with a regular life like the rest of us.

  3. Maybe antidepressants would have helped.