Tuesday, August 30, 2011

Say “person with schizophrenia”, not schizophrenic!

                When someone is called a schizophrenic, the word tends to describe them as a mass of symptoms that defines them.  Saying a person has schizophrenia better describes a complex person who is diagnosed with a disease. I have met thousands of people with schizophrenia. They are brothers, sisters, sons and daughters, mothers and fathers. They are liberal and conservative, Jewish, Catholic Protestant, Hindu and Buddhist. They are smart and stupid, interesting and dull. They are never the same although they often have symptoms that are similar.  They have hobbies and interests, hopes and dreams.  Most importantly they love and are loved.
The Story
Her young son stood behind her when she opened the door. He was 9 or 10, with jet black hair and big brown eyes. “I.D,” she demanded.  When I handed it over, she looked closely at the picture and at me, and then examined the lamination to make sure it had not been tampered with.  “We’ll talk outside.  You stay here and lock the door,” she said to the boy. She was a tall white woman 5’9” or 10”, with long brown hair.  Her face was thin, pinched and with a small mouth.  “I don’t know why the cops came, I wasn’t bothering anyone.  I was just talking to my son.”  “I guess the neighbors thought maybe somebody was bothering you or hurting you or your son,” I said.  “Also, you gave the police a false name and your son hasn’t been to school.”  “I told them that I had to escape my ex-husband who is trying to kill me. He has access to all FBI and CIA records and if I use my real name he can easily find me.  He’s found us in Flagstaff, Arizona, Rockford, Illinois and last month in Charleston, South Carolina.  He even had me raped in Charleston,” she replied.
The officer, who alerted me to Kristen and her son Adam, had contacted the Charleston police for information. They’d had a dozen difficult contacts with Kristen in the six months she lived there and confirmed the sexual assault had taken place about a month earlier.  They had a suspect in the case, who was also being investigated for other rapes, but they did not have enough for an arrest. 
Kristen claimed her husband was a member of the Noriega family and had been working as a CIA informant and as a drug runner and was part of the “Miami Mafia”.  “He has a long reach! People think I’m lying or crazy, but I know it’s true.  Look at the things that happen to me. How else can I be followed all over the country?  There are things that go on that we can see that are on the surface, and there are things that go on under the surface.  The things on top are controlled by the people underneath. I’ve been working for a number of years on a book that will expose the connections between corporations and the mafia.  There are great libraries here at Cornell and I’m going to spend time doing research so I can expose the system that nobody sees.  I hope I can hide out long enough to do my work.”
 “It sounds like you have really been through a lot,” I said.  “We keep our information strictly confidential.  The records we keep are only paper records.  We don’t keep any computer records at all. We won’t for at least a few years.  There is a woman I work with named Anne who specializes in helping women who have been oppressed by the men in their lives.  She also helps women who have been sexually assaulted. I’d love for you to meet her.  Would you do that?  And your son has to go to school. I’ll talk to them about securing his records.”
The psychiatrist who presented her case at our intake meeting was not optimistic. “This 36 year old woman had an onset of symptoms of paranoid schizophrenia at about age 22, shortly after her college graduation. We have received hospital records from her home town, Baltimore.  She was reluctant at first to sign a release, but after much discussion and prompting, she agreed that it would be helpful for us to confirm facts as she states them.  She is a traveller.  The only region she hasn’t been in is the Pacific Northwest and not for want of trying. She says that she was in Salt Lake City at the bus station with a ticket to Seattle when she saw her husband at the ticket office talking to the agent. Kristen says that she is happy to talk to Anne, but is unwilling to take medication.  I also saw her son and spoke to him with her present and by himself.  He is a nice young boy.  Mostly, he’s worried about his mom, who can go on rants about various delusions she has.  That was what the original call was about.  As far as the ex is concerned, I don’t know if he’s a good guy or a bad guy.  At the moment, we have no reason to look for him.  What I do know is that she has had some very bad things happen to her and for the sake of her son; it would be nice to try to engage her and have her want to stay here so her son can have a life.  But if she’s still here six months from now I’d be surprised.”
I heard the piano when I came down the stairs. Anne had called me and asked that I come down to the day treatment program.  It was late in the afternoon, the program was over and when she said it wasn’t a crisis, I’d been relieved.  The old upright was in a corner and usually it was subjected to unending versions of “Chopsticks”.  The sounds that came from it now were melodic and sweet. I recognized the song as an old standard, What a Difference a Day Makes.  When I was able to look over the top of the piano I was shocked to find a little boy with ink black hair and brown eyes.  His small hands moved easily over the keys, his gaze intent on the sheet music in front of him.  He picked up the tempo and the song took on a different flavor.  “I heard it played faster once,” he said, looking up at me.  An hour later, after preforming songs from West Side Story, some ragtime, and then Bach and Chopin, Kristen came in to get him.  “He’s good, isn’t he?”
Anne told me that Kristen recognized Adam’s talent early on.  In each community they had lived, Kristen had arranged piano lessons.  She’d scrimped and saved and traded labor and bartered belongings for the lessons.  What was clear was that this very charming and pleasant young boy had exceptional talent that needed to be developed.
Kristen’s agitation, including yelling, continued to cause problems.  The psychiatrist had given her a prescription for anti-psychotic medication that he said would “calm her”.  He told her that she was in charge of her treatment and she should take the medication if she felt an episode coming on or if the neighbors complained or the police showed up.  “It does take the edge off,” she told him at their next meeting.
After about eighteen months passed, Adam was nearing the completion of his first entire year in one school.  Kristen had joined our day treatment program and was a regular, cooking and serving lunch to some severely disabled clients.  She came to my office one day in April to brainstorm about ways to finance a summer arts camp for Adam in a nearby city.  I directed her to some local charities that I knew could help.  When she came up a few hundred dollars short, we took up a collection and I told her it was from a special charity.  It took three buses and a mile walk for her to take him there.  She’d spent the night on a bench in the bus station before returning the next day.
The regional orchestra that Adam performs with now is a five hour drive away.  I saw him just after he graduated from college.  “My mom’s crazy, but she loves me,” he said.
The Stories
The stories are my remembrances. Each of them is based on a true event in my work for Tompkins County Mental Health. I have changed the names and identifying information of every client, patient and co-worker except for Beau Saul, of the Ithaca Police Department, who I was fortunate enough to have as a partner. When confidentiality demanded it, I have changed details. The dialogue is my reconstruction of what was said at the time.   I have felt honored to be let into the lives of so many individuals over the years. Their stories are a gift I have been given.  Please enjoy them in the spirit with which they were written; to educate and inform.

Thursday, August 25, 2011

If you have a serious mental health problem, find a skilled helper!

There are many different kinds of mental health professionals.  Often they claim a broad knowledge base and are willing to see anyone who comes through the door.  If you have a serious mental health problem, check around. Contact your local mental health association or the local affiliate of the National Alliance for the Mentally Ill, (NAMI).  Have a brief phone or face-to-face consult, which should be free.  Make sure the person is skilled and knowledgeable.  Talk about cost and insurance.
The professional should be helping you set goals and objectives early in the process.  Avoid “chit-chat” therapists who don’t have a plan and talk to you like an interested friend.  You ought to know where you are going in treatment and how you are going to get there.  You should be learning skills and be able to apply them in the real world.  Insight is not enough!  Change needs to take place.  A skilled mental health professional should know about “talk” and “non-talk’ treatments and be open to at least discussing all possibilities.  If, after three months, change is not taking place, find another professional. 

The Story

The smell of gasoline was frightening. It enveloped the entire space.  The empty gallon can was next to her on the concrete floor as she sat there sobbing, her hair and clothing covered, soaked with the fuel that was slowly evaporating. In her hand was a shiny zippo lighter. Its reflection sent splashes of light throughout the two car garage.  I sat on an overturned five gallon bucket near a side door to the room. The cars were parked in front and I could see the lights of the police cruisers flashing against the leaves of the trees in the early autumn afternoon. She was a thin, small white woman in her mid-forties. Her damp hair may have been blond. Her white sleeveless blouse and grey sweatpants were saturated, her feet were bare. The garage was silent except for the buzz of the florescent bulbs overhead.
The therapist had come running down the hallway waving a folder in her hand about two hours earlier. “Terry, Terry, you’ve got to help me. She’s going to kill herself. This time she’s really going to do it.”  I sat her down and had her tell me the whole story. Her client had a long history of depression. She had been seeing her for eight or nine years.  Our new psychiatrist had recommended medication for this patient and Diane, the therapist, had not only resisted, but had poisoned the person’s attitude regarding medication. She was an old school therapist who was taken to saying, “People have to work through their issues. Medication is just a short cut, a band aide that doesn’t solve the problem. They need insight and understanding into the reasons they are depressed. They need to take responsibility for their part in their depression.”  This particular therapist had a caseload of depressed women who she had been seeing for years and none of them ever seemed to get better. Her notes always indicated that her clients were “gaining insight” or on the verge of having a “breakthrough”.
When we had reviewed this case a few months earlier, we had noted the length of time the patient had been in treatment without real progress. Our recommendation was to begin a trial of Prozac, a medication that had only been available for a short time. I understood the resistance to the older antidepressants, the tricyclics, like Elavil and Imipramine. Those medications were very useful except for a major problem. A month’s supply would kill you. Prescribing the means to end your life to a depressed, suicidal person was risky business and in the thirty years they were in use, these medications killed many.  Prozac did not have this problem and was a game changer. Professionals had to be convinced, but many didn’t have an interest in rethinking the way people with serious depression might be helped.
The therapist was rocking back and forth in her chair saying, “Hurry, you’ve got to hurry.”  I scanned the folder in front of me and called the sheriff’s dispatcher. The response was: “We’ve got a car out on the lake road. He can meet you and you can follow him out.”
The initial call had come from the woman’s boyfriend. Lenore had been having increasing suicidal thoughts and had been fighting an impulse to kill herself for an entire week. The boyfriend had locked his rifle in the car, hid all the sharp knives and cleaning products and hoped Lenore would make it to her next appointment. That morning they had argued about something minor and he had gone to the store. When he returned, she was in the garage covered with gasoline. “Stay away from me,” she had screamed at him, and he called her therapist. He went to the door of the garage and told her someone was coming out to talk to her and proceeded to the end of the driveway to wait.
I pulled up next to the deputy’s Crown Victoria and briefed him on our call.  “Follow me. Stay close,” he said smiling, and then his wheels spit gravel at me as he took off, his big lights flashing.   My official county car was perhaps the worst car ever made, the Ford Escort. It was small and cheap and when you stepped on the gas the engine made a roaring noise and the car hardly moved. We had a twelve mile run into the country and even though I repeatedly called on the radio to slow down, the deputy kept us moving at about eighty. The front end shook, the doors rattled, wind made the hood lift slightly as if it would fly into the windshield. We passed semi’s from the salt mine and school buses full of kids and when I realized my life depended on it, I got about six feet behind that cruiser and stayed there.
The boyfriend was leaning against a fence having a smoke when we got there. “I can’t take this crap much longer,” he began, and I had him fill me in on recent events. The deputy said, “I called an ambulance. I’m going to wait out here. If you need me call me.” I replied, “Get the fire department too, and remind them both to approach silently.  I don’t want to have to yell over the sirens. And tell them to stay out until I call them.”  “You’re the mental health expert!” he responded.
The adrenaline from my drive was beginning to dissipate when I opened the door to enter the garage. The smell was overwhelming. “Lenore?” I asked, as I observed the figure on the floor. “Don’t come near me,” she yelled, flipping open the lighter. “I’m going to stay right here. Do you mind if we talk?” I asked, introducing myself. “I think we met once in the waiting room, can I open the window? The fumes are making me a little dizzy. I’m going to sit on this bucket.” “Ok, but just stay away,” she replied.
“Tell me what’s going on?” I asked. I want people in crisis to tell me their story and she did. It was a sad story, a difficult story, one that had no simple resolution. It included a problematic childhood and the betrayal of friends. She spoke of missed opportunities and unfortunate decisions that created unpleasant consequences she had to live with. There was a sadness that permeated everything.
“I’m so sorry. That sounds awful,” were my responses to the pain she expressed.  “Why now, why today?” I asked.  “There was nothing special. When I woke up I just felt like I couldn’t deal with it anymore. There is no end in sight and I’m so tired.” She began to cry, first tears running down her face, then sobs that shook her body.
“How about this? Clearly you are overwhelmed and can’t see any resolution to the problems you’ve described, but you’ve also told me about good things in your life.  What if we get you some place where you are taken care of, where the worries can be put aside and you can try to focus on the few things that have taken you to this point?”  She slid the lighter across the floor to me.
When she was discharged a month later on Prozac, I assigned her to a new therapist. Three months later Diane resigned, wanting to devote herself full time to her private practice.

The Stories
The stories are my remembrances. Each of them is based on a true event in my work for Tompkins County Mental Health. I have changed the names of every client, patient and co-worker except for Beau Saul, of the Ithaca Police Department, who I was fortunate enough to have as a partner. When confidentiality demanded it, I have changed details. The dialogue is my reconstruction of what was said at the time.   I have felt honored to be let into the lives of so many individuals over the years. Their stories are a gift I have been given.  Please enjoy them in the spirit with which they were written; to educate and inform.

Thursday, August 18, 2011

Unconditional support provides positive outcomes

Schizophrenia is a very isolating disease. The positive symptoms; hallucinations and delusions, are not shared experiences. The expression of these symptoms  tend to frighten and drive away those closest to the person experiencing them.  The negative symptoms: lack of interest in the world and a diminishment in the ability to experience pleasure, further separate the person from their surroundings.  In order to be successful in treatment, an individual must have someone on their side. This unconditional support is often the basis for positive outcomes in treatment.  Families should be natural allies, but may end up being seen as enemies as a result of symptoms.  Friends are hard to maintain and professionals who may be caring have to maintain a distance.  However, support must come from somewhere.
                As we recognize schizophrenia for what it is, a brain disease, we must also recognize that we can’t abandon people because they have symptoms that are difficult or unpleasant.  This story speaks to the kind of support that creates a successful outcome.

The Story

“The kid is just standing there in the main library, not moving, not really saying anything. When I try to get him to come with me or do anything, he just looks at me sideways with a smile on his face.  When he says something, it’s just gibberish.  The sergeant says you need to come up and take a look at him. He’s not really causing any problems, breaking the law or anything, no danger to self or others, just out of it.” I put down the phone and drove to Cornell.
            He was halfway down an aisle in the stacks. He was moving his head up and down slowly, in a jerky motion, the way a parrot does. The cop had gone to the other end of the aisle to try to control the situation if things turned to crap. Another cop was behind me. No one knew the young man’s name, but he looked like a student.  White kid in his early twenties, 5’10” short brown hair, average build, wrinkled jeans and a tee shirt.  His hands and arms were also moving in a slow jerky motion almost like Tai Chi. “Hey”, I said walking up to him, but not within arm’s reach. “I need to talk to you. What’s your name?”  He looked at me and smiled.  I continued, “People are a little concerned about you. You’ve been standing in this same spot for about five or six hours and you don’t answer when people try to talk to you.”  He didn’t look at me but began to speak, “You or not you, to be or not to be.” When he finished he started laughing, then tilted his head up and to the side, obviously listening to voices that only he could hear. “I’ll be right back,” I said as I went to the cop behind me to make a request. I returned to the young man and attempted to engage him in a variety of ways while I waited. Nothing worked.
Ten minutes later an EMT showed up with a gurney. I rolled the gurney between the shelves and parked it next to the young man, locking the wheels with my feet.  I pulled down the top sheet and said, “It is very important that you lie down on this. Your legs are sore and you are very tired. Your back must be stiff too.  If you lie down on this, you will feel much better. Take two steps and climb up on here”, I said, patting the bed. The jerky motion stopped and he took one big step and settled his rear on the gurney, then turned to lie flat, his arms at his side, eyes staring at the ceiling. I pulled the sheet over him and buckled a belt over his chest, pinning his arms. The cops and EMT’s took over, adding more belts and rolled him out the door.  Before they put him in the ambulance, an officer patted him down and got a wallet from a front pocket.  His name was Louis and he was a junior at Cornell. Before I left campus I went with a cop to his dorm to talk to his roommate. I wanted to get as much information as I could to give to the hospital for assessment. The emergency room folks could call his parents.
            “I haven’t seen him for a couple of days. We’ve been roommates for two years. He’s a good guy, English major. But lately he’s gotten really strange. Sometimes he just stares into space or he’ll disappear for a day or two. At first I thought maybe he had a girlfriend, but I don’t think so. We really hang out with different people. As a matter of fact, he doesn’t really hang out much at all. The first couple of years he was doing club volleyball, then that stopped. I don’t know how he’s doing in his classes, but he did pretty badly last semester. I hope he doesn’t flunk out.”  He went on to say he didn’t think that Louis used drugs and that he hardly ever drank. “He always worked hard and kept to himself. You were more likely to find him in the library on Saturday night than at a bar. But one thing he does do is attend that little church on the edge of college town. I went with him once, not holy rollers, but sort of fundamentalist. It wasn’t for me, so I never went again.”
            Louis was from Queens, in New York City and it seemed that this was not the first time he appeared to be having a psychotic break. The previous summer he’d been sent to the hospital after walking among traffic on a major roadway. At the time, his parents were convinced that someone had “slipped something into his drink.” According to the record they were unaware of any mental illness on either side of their families although on the husband’s side there was strong evidence of substance abuse.
            He was referred to our clinic from the hospital after a two week stay. Mental health services at Cornell are very good, but they tended to defer to our greater experience and services when a person has a chronic psychiatric illness.  When we first met, Louis was somewhat coherent. However, it was clear he was very symptomatic with what are known as positive symptoms like hearing voices or feeling controlled by others. Much of our initial conversation was interrupted by Louis cocking his head to one side, concentrating on the words the other voice spoke to him.  He was a very smart, articulate and pleasant young man who agreed that he needed a medical leave from the university.  He described a family situation that was less than ideal and decided to stay in Ithaca.
            Louis took medication like many other patients at our clinic. As the unpleasant symptoms began to diminish, the unpleasant side effects of the medication began to be a problem. Feeling better often made things worse. He started to take medication on an “as needed” basis and it did not work very well. Missed appointments became common.
I saw him walking slowly down the street one day and approached him. “I want you to come and see me,” I said. “I see you and I see beyond you,” he replied laughing. As we walked, he made eye contact and bowed slightly to the people walking by.  “My subjects,” he explained. In fact, his contagious smile and nodding elicited a similar response from everyone we passed. “You need to start taking medication again!”  I stated emphatically.  “That’s right,” he exclaimed pointing in front of him. “That’s right!” he said again. It took me a moment to understand that he was pointing at a line of three or four cars in a turning lane in front of us, their right blinkers on.  That afternoon he started an injectable medication that he responded well to.
            Two weeks later, Louis showed up at my office with a middle-aged man dressed like a golf pro. “I’m Pastor Johanson, Gary Johanson. Louis belongs to my church.  He’s been a member for two years. He’s told me a little bit about his problems and told me about you. Last Sunday during service he spoke about some of the things on his mind. Not all of it made sense. I wonder if there is a way we can help.” I asked the pastor to leave the room for a moment to make sure Louis wanted this man involved.  When the Pastor came back in, I said to him, “Louis has been having a difficult time following through on his treatment. He certainly needs encouragement to be fully engaged in the process.”
            On Sunday, a month after meeting with Louis and his pastor, I found myself at the podium in the front of their church. Nearly eighty people had stayed to hear my talk about mental illness and treatment. Pastor Gary had purchased ten copies of Surviving Schizophrenia, by E. Fuller Torrey, and people agreed to read it and pass it on.  Louis sat next to the pastor in the front row. His smile was less infectious, but more genuine. When my talk ended, Pastor Gary offered juice and cookies in the church basement. But first he asked us to bow our heads, “Merciful God, let us join together to help and heal each other.”
The Stories
The stories are my remembrances. Each of them is based on a true event in my work for Tompkins County Mental Health in Ithaca New York.  I have changed the names of every client, patient and co-worker except for Beau Saul, of the Ithaca Police Department, who I was fortunate enough to have as a partner. When confidentiality demanded it, I have changed details. The dialogue is my reconstruction of what was said at the time.   I have felt honored to be let into the lives of so many individuals over the years. Their stories are a gift I have been given.  Please enjoy them in the spirit with which they were written; to educate and inform.

Wednesday, August 10, 2011

Bi-polar disorder can be a lifelong illness

Bi-polar disorder can last a lifetime. Although, there are often periods that are symptom free, bi-polar disorder is a recurrent illness. It is estimated that 90% of those who have a manic episode will go on to have future episodes. Often, episodes of depression and mania can follow quickly, at times caused by the medication used for treatment.  In my experience, it was common to see patients become manic after a depressive episode as a result of the introduction of antidepressants.
Bi-polar disorder is viewed primarily as a mood disorder.  But it is common for people with serious bi-polar disorder to have some symptoms of thought disorder associated with difficult episodes. Psychosis that may include hearing voices or paranoia may be part of the symptom pattern. These may occur during the extreme phases of mania or depression. Whether the symptoms are primarily mood symptoms or thought symptoms, the person’s ability to have good judgment is impaired.  The incident I recount is an example of  how the illness can be a lifelong problem.
The Story
The woman with the knife to her throat was shrieking at me through the door, “I’m going to kill me! There’s nothing you can do to stop me.” When I peered through the glass I saw the big kitchen knife, the largest in the set, clasped in her right hand, the sharp edge against her throat. Four dogs surrounded me on the small deck in front of the trailer, barking furiously and nipping at my legs.  All of them were old and tired, but could not ignore their master’s screams.
                Mrs. Johnson must have been in her mid-seventies. She’d had a lifetime of bipolar disorder and had spent from her early twenties through her forties at Willard Psychiatric Center, a big old fashioned state hospital in farm country along Seneca Lake in upstate New York.  She’d had several hundred electro convulsive therapies (ECT) also known as shock treatment. She’d had insulin shock treatment that involved insulin injections that made her comatose. In the late 1950’s she’d been scheduled for a lobotomy, but had improved enough to escape that procedure.
                She was a patient at the county outpatient clinic for twenty years and like everyone who had treatment there I’d looked at her records, including volumes from Willard that filled four three ringed binders. They didn’t tell me much about her, but they did tell me what happened to her; the treatment they provided, the long years she’d spent “improving”. Her family information introduced me to a rural extended family that lived along a few roads in a deep valley a dozen miles from Ithaca.  Their ancestor was one of the original settlers of the Finger Lakes who’d fought in the revolutionary war and received a land grant.  He’d then purchased more grants to create a homestead of a couple of thousand acres. Now days the family has a broad reach of education and vocation. They are dirt farmers, shade tree mechanics, college professors, nurses and every other sort of person a family can produce in over 200 years.  What they had in common was the land that the family inhabited in every form from mcmansion to broken down trailer.  It appeared that no family member ever left.  When you reached 18 or got married or returned from college, they cut out a piece of land and it was yours.  That was how Mrs. Johnson got her two acres. A cousin drilled a well, someone else brought in a backhoe to dig the septic system and after the electric pole was put up her brother brought in a ten year old trailer and set it on cinder blocks. It was a single wide, long and narrow, surprisingly pleasant and comfortable on the inside. 
                In recent years, Mrs. Johnson had been doing very well, taking her medications, having her blood work done and eating and sleeping on a regular schedule. She was an avid gardener. The flowers that lined her path and surrounded the base of her trailer began to bloom in early spring with daffodils and ebbed and flowed throughout the summer and fall, a riot of color that reflected many of Mrs. Johnson’s moods.
                 This latest episode had begun almost two months earlier, when at a regular clinic appointment she announced to her psychiatrist that she had stopped taking her medications.  When the doctor presented her case in a meeting, he described a failed attempt at reminding her that two thirds of her life had been taken from her by illness and that she currently had a terrific existence that she was putting at risk.  Her response, read from his notes stated: “I don’t care one damn bit about your opinion. I feel fine, better than I felt in my whole life and I don’t need your pills.”  Our crisis team had one more name added to out “hot” list.
                From that time until my visit, it had been like watching a slow motion train wreck. First her brother called, heartbroken but resigned, he described her coming to his house at two in the morning to renew a family dispute from a decade earlier. Her family doctor called me the following week to say that she’d shown up without an appointment demanding he give her a prescription for birth control pills because she was going to become sexually active. Next, was a State Trooper who had written her a ticket for speeding and passing a school bus. “She was really crazy. I don’t know what you can do, but you better do something because she’s going to hurt someone.”  I’d visited her at home twice and she yelled at me through the door. Two days earlier she’d hung up on me when I called. Her mania had moved into an agitated depression that had her lashing out at anyone she had contact with.
 That morning her brother called as soon as I got to work. “She is out of control. You need to bring the cops with you when you come.” I walked away from the door when I saw the deputy’s car stop near the edge of the property. When I waved, he pointed his thumb backwards and reversed the car, hiding it behind a row of bushes.  When I got to his door he got out, unfolding himself to a height of 6’6”. He was as broad as he was tall. We’d known each other for a while and I was happy he’d been the one on duty. “What have we got?”  He asked. When I told him, he said, “Oh yeah, I dealt with her before. She can really get going, but otherwise she’s a nice old lady.
He went to the trunk of his car and got a pry bar. “Anybody else coming?” I asked. “Nope! Sorry, but there was an accident up at the airport and the trooper from this side of the lake is up there. I called an ambulance; they’re about three minutes out. It’s just us playing cowboys and Indians by ourselves. Here’s the plan: If she knows I’m here that will make it worse. So, I want you to go to the door and see if she’s still screaming with the knife. I’m going to sneak up along these bushes and get in next to you. Try to get the dogs behind the screen door when you open it.  I’m going to pop the door with this bar and land on top of her. You get the knife.”
 As I walked past her car I opened the rear door and three of the dogs jumped in. That got me a thumbs up from the deputy. Approaching the trailer, I could hear that the screaming was louder. Up on the porch I wrapped my jacket around my right hand and got in place while the deputy, who’d come up behind me, placed the bar between the door and frame. “Go!” He yelled. The door hit her when he banged through it and he was on top of her trying to hold her arms. I put my coat on the knife and pushed it to the floor. I then carefully pried her fingers off the handle and pushed the knife away.  He rolled her and cuffed her and called the EMT’s on his radio to come and get her.
 Her brother was walking down the road towards us while they were loading her onto a stretcher into their rig. “Hey Andy”, the deputy called,   “good to see you. When you come over next week, bring your boys, we’ve got some new dirt bikes.”  He turned to me, “Andy’s married to my wife’s cousin.”

The stories are my remembrances. Each of them is based on a true event in my work for Tompkins County Mental Health in Ithaca New York.  I have changed the names of every client, patient and co-worker except for Beau Saul, of the Ithaca Police Department, who I was fortunate enough to have as a partner. When confidentiality demanded it, I have changed details. The dialogue is my reconstruction of what was said at the time.   I have felt honored to be let into the lives of so many individuals over the years. Their stories are a gift I have been given.  Please enjoy them in the spirit with which they were written; to educate and inform.


Sunday, August 7, 2011

A recovery treatment model

A New York Times article describes a hybrid approach to managing schizophrenia. There are ways that people can manage the stress that brings on symptoms, but also use medication as needed. What's missing in this article is a look at the course of illness. For some people, as they get older, the symptoms get more manageable. Below is the link to this August 7, 2011 article:
Lives Restored
Learning to Cope With Schizophrenia
Joe Holt spent years trying to determine the cause of his problems, before deciding to find a way to live with them.

Wednesday, August 3, 2011

Obsessive Compulsive Disorder - Rituals in Control

Obsessive Compulsive Disorder commonly known as OCD can be one of the most debilitating problems one can face. The National Institute of Mental Health describes it this way: “People with OCD have persistent, upsetting thoughts (obsessions) and use rituals (compulsions) to control the anxiety these thoughts produce. Most of the time, the rituals end up controlling them.” The thinking is very hard to control and it drives the behavior which can be treated with therapy as part of a difficult process. Medications may also help.
All of us have rituals. They help us get through the day, from morning coffee to evening prayers. Many of us check multiple times to make sure the stove is off or the door is locked. It is when these rituals take over and interfere with our lives, that there is cause for concern. We are unsure about the causes of OCD and the symptoms can ebb and flow. It’s often accompanied by other anxiety disorders and depression. The following story gives an extreme example, but not as uncommon as people would think.

The Story

                He sat cross-legged on the floor, dressed only in his bright, white underwear. Tears ran down his face. Next to him on the floor was a bucket filled with water, a sponge and a scrub brush. Folded neatly in his lap was a pair of bright yellow rubber gloves. He shook his head from side to side in disbelief that I had entered his house. I had removed my shoes and put on surgical gloves that I got from a box I always kept in the car. “My God”, he said, “now I don’t know where to begin.”
                His ex-wife had called to say she had not been able to reach him on the phone. “I’m concerned, not worried really,” She told me. “He could be standing next to the damn thing while it’s ringing, but if it isn’t cleaned properly or if he hasn’t performed the proper ritual, he won’t answer it.  I’ve seen it happen a hundred times.  Another thing that happens is he’ll sort of get stuck, like he is overwhelmed with what he needs to do and he’ll forget what he’s cleaned and he is immobilized. Maybe you could stop by and see if he’s ok.”
                Elliot’s ex-wife was the person who introduced him to me two years earlier. He’d moved to Ithaca from Newark, New Jersey, after things fell apart for him. He’d been a mechanic for the New York City subway system for twenty six years when his obsessive compulsive disorder got the best of him. He’d taken early retirement and picked Ithaca because a high school friend lived here and he’d visited a number of times and liked it. 
His ex-wife was also his best friend. They’d married young, both of them just 20. He’d been discharged from the army less than a week. She got pregnant on their honeymoon and again a year later while nursing her first daughter.  He took the skills he learned in the service and was offered a position with the Transit Authority.
                When her youngest daughter went to college, Amy told Elliot she wanted a divorce. She moved out of their house and into an apartment. She told me why when we first met. “He was driving me crazy. Not only the cleaning thing, but everything.  It was classic!  Checking the stove and checking the locks on the doors and windows and being afraid to go anywhere in the car because it might break down. I started to think I might lose my mind.”  Elliot had not disagreed with this assessment when I met with them both. He also agreed that things got a whole lot worse when Amy was gone. He hadn’t realized what a moderating factor she’d been in his life until she left.
                “A geographical cure!” the psychiatrist had said after seeing Elliot. “It rarely works.” Elliot had refused to take medication at that time. “It makes me feel drugged. I can’t get anything done.” Later, he’d agreed to have some medication in the house for those times when he felt completely overwhelmed. His effort to integrate himself into life in Ithaca was limited. The old friend got tired of him fairly soon and Elliot became as isolated here as he’d been in Jersey.
                “Can you get up?” I asked, offering my hand. “My legs are pretty cramped. What day is it?”  He asked as I pulled him up. When I told him, he determined he’d been on that spot on the floor for about eighteen hours. “I got to pee!”  He announced and went down the hall to the bathroom. When he returned, I handed him a pair of pants and a tee shirt and we went outside to his front steps.  He and I had been through this a couple of times before and we both knew the routine. Essentially, I had contaminated the entire apartment and when I left, he would start again from the doorknob inward. In the past, he’d allow me to visit and knock only if I had on rubber gloves and then we met on his steps.
                He was tall and thin with graying hair in tufts on the front of his head. I started to explain, “I’m sorry, Amy called and was worried. When you didn’t answer the door I got a key from the landlord.” “No problem,” he said, “there were guys in to replace the stove two days ago. I told the landlord that the old stove was fine, but he insisted and finally got sort of pissed and sent his guys over. I started cleaning after that. And the new stove is really nice.  When I got to the second bedroom upstairs I cleaned myself into a corner. The floor was wet all around me, so I thought; I’ll just let it dry and go downstairs. After it dried I didn’t really know where I’d cleaned so I stayed put. The phone rang about a dozen times. I knew it was Amy or one of the girls and they’d understand.”
 I always found it interesting that when Elliot and I ended up on the steps together, how utterly normal he could be. It was like he was taking a break from his psychological problems. We’d chat and joke and make small talk as if his life had not been ruined by his condition. “What do you think about seeing Kevin again,” I asked, referring to the psychologist he’d worked with in the past. Kevin had used a form of classic exposure therapy with Elliot, having him make contact with various objects that others have touched. Elliot had once walked through the entire building touching doorknobs. He ended the session with both hands on the handles that opened the front doors of our building which hundreds of people touch each day. It appeared that Elliot was making progress, getting out, keeping appointments and attempting to make a life for himself when all of a sudden he stopped.
                “I don’t think so,” Elliot said, referring to my question about treatment. “I like Kevin, but that stuff wasn’t really working for me.” I tried a different tack, “How about if he came over here and worked with you here? You could try some small things, like how to deal with the phone or people coming to the door. Also, you have to figure out a way for your caseworker to help you buy food. She can’t spend the whole day with you, she has other clients. Kevin might be able to help with that.”  He replied, “I really appreciate what you’re trying to do and I know that exposure helps some people. It just didn’t seem to help me. It made me more anxious. Besides, now when I’m doing real bad I take the pills, they help a lot. I just didn’t have them with me this time. I’ll make sure I keep them close so this doesn’t happen again.”  He held up his red, raw hands, palms up near his shoulders, blending surrender with goodbye. “Thanks for coming by.”
                The U-Haul with Jersey plates was almost full. Amy and two young, attractive women were putting plastic bags of clothing on top of the furniture, before pulling the door down and locking it. Elliot sat in the front seat, his eyes closed, his head resting comfortably on a clean white towel covering the headrest. “It’s for the best.” Amy said to me, shaking my hand.

The Stories
The stories are my remembrances. Each of them is based on a true event in my work for Tompkins County Mental Health in Ithaca New York.  I have changed the names of every client, patient and co-worker except for Beau Saul, of the Ithaca Police Department, who I was fortunate enough to have as a partner. When confidentiality demanded it, I have changed details. The dialogue is my reconstruction of what was said at the time.   I have felt honored to be let into the lives of so many individuals over the years. Their stories are a gift I have been given.  Please enjoy them in the spirit with which they were written; to educate and inform.