Saturday, October 22, 2011

Difficult lives can create challenging problems.

There are some people who live such difficult lives it is hard for us to imagine.  Pain and suffering are joined with fear in ways that produce unusual patterns of behavior as a way of coping. We can pathologize those behaviors if we are willing to help. But we must be careful about judging them.

The Story

            Her face had been sliced and cut at least fifty times. She looked like she’d been in a horror movie. The razor blade was still in her hand. “Would you please put that down?” I asked. “What? What?” she whispered back at me. “The razor is in your hand. Could you please put it on the table behind you? Can I come in?” “Yeah, sure. Come in.” As she backed into the house, I picked up a book from the same table and placed it on top of the razor, hiding it. “What do you want?” she asked, irritated that I had entered her world. “I need to make a call, give me a minute.” I said as I dialed the house phone to central dispatch asking for an ambulance and a deputy. “Shit”, she said, “Not the cops, there’s really no need for the cops. I’m not going to do anything stupid.” I remembered some time earlier that year when she had threatened suicide and made the same promise. While she and I were walking to the car, she pulled a piece of broken glass from her pocket and slit her wrist. I wasn’t taking any chances this time.
            I went to the kitchen and got some paper towels. ”You’re bleeding!” Many of the cuts were superficial, but some looked deep. There was blood in her hair and down the front of her shirt, on her jeans and splattered throughout the house. Her hands looked like they were covered in rust. I doubted she had even looked at herself since she’d started cutting. When she cut, it was usually slow, a process that could take hours, something she could savor like a fine meal.
            “What are you doing here?” she asked. I replied, “Dave called me and told me that you’ve been having a rough time. When he left to go to work, you promised that you would answer the phone. But you didn’t. I see the answering machine has eight messages on it. Two are from me. I had to come out this way for a home visit and I thought I’d stop by.” “You have no right to be here,” she said. “When I knocked on the door, you opened it and invited me in,” I replied.
            She had bunched the paper towels into a ball. She sat and stared at them. “I need my glasses. They’re in the kitchen, can you get them?” I went to the kitchen and found the glasses on the table next to a box of Cheerios. The dishes were done, the counters were clean. I was sure that after Dave went to work she’d fed Maggie, then fixed her lunch and sent her off to school. I went back to the living room and gave LeeAnn her glasses. “What time is it?” she asked. “Almost two. What time does Maggie get home?” I asked. “The bus comes at two thirty.” she answered. “Is there anyone who can stay with her until Dave comes home?” I said. LeeAnn picked up the phone and called a neighbor who agreed to meet her daughter and have a play date with her own child until Dave got out of work. She then returned to her chair and the ball of paper towels returned to her hand.
            “Do we really have to do this? I’m okay, I really am?” she said, pleading with her eyes for me to just disappear. I was tempted to have her look in the mirror. But her appearance was so shocking, I was afraid of her emotional response. Her history of dissociation had begun in childhood with daily physical and sexual abuse. She’d described to me how horrible her life had been. I was aware of her extended family, with generations of sexual abusers and victims, men and women, taking on both roles. The families poverty had been spread out over two rural roads with broken down trailers and roughhewn cabins, most of which had no running water and were heated with wood or kerosene heaters. The children who lived there were dirty and strange, almost feral. They existed on canned goods from food pantries and school lunch programs. The adult men seemed always to be working on rusted out trucks in the yard, small groups of them under the hood or searching for tools. The women were inside watching talk shows on small old televisions.
            LeeAnn had escaped. She’d graduated from high school and worked at Cornell in food service. She’d gotten her rotten teeth fixed and been presentable enough to become a supervisor. She met Dave when he made a delivery of paper goods for the restaurant supply company he worked for. They only dated a short time before they were living together and got married after she became pregnant. Somehow she was able to keep her cutting a secret for most of their early years together. She explained her dissociation as being “spaced out”. As a young mother she was able to juggle job and home as well as anyone. When her younger sister died she went off the rails. Her sister had tried to follow in LeeAnn’s footsteps and might have succeeded if she hadn’t gotten involved with a man who was like all the men in her family. He threatened and bullied and abused. LeeAnn’s sister found the only way out; she took her life.
            The death brought back all the feelings of fear and helplessness and guilt. “I go away! I just go away.” was what LeeAnn had told me when I asked her about what she described as “missing time” each day. “You know when you’re driving on the interstate, and you realize you’ve passed three exits you didn’t notice. It’s like that.” LeeAnn’s therapist had been working hard, using a variety of therapeutic approaches to help LeeAnn. I supervised treatment and we agreed that LeeAnn needed to retain a high level of functioning to be able to stay in her marriage and raise her child. It was difficult to tell how successful we were.
            I could hear the diesel engine of the ambulance as it pulled in front of the house. I went to the door and opened it. “You don’t need the gurney. I’ll walk her out.” LeeAnn continued to stare at the balled up paper towels. “LeeAnn, they’re here. Will you walk out with me?” She stood up and stared at me and I followed her out the door.

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.

Sunday, October 16, 2011

When Truth Lies available as an eBook

When Truth Lies, the first real novel about schizophrenia, is available today as an ebook. Print copies will be available for purchase beginning October 24, 2011. To find out more, or read an excerpt, go to

Praise for When Truth Lies from Dr. E Fuller Torrey-
[Garahan] "writes clearly and well, and the subject is certainly appealing." -Dr. E Fuller Torrey, author of Surviving Schizophrenia and the Insanity Offense

Friday, October 14, 2011

Context can create understanding

            There are actions that people describe as “crazy” that really aren’t as crazy as they seem.  Rather than saying what someone is doing is crazy, I often start with, “I don’t understand what that person is doing or why they are doing it.”  The action, in and of itself, is most often neutral. When we call it crazy there is a judgment attached that may or may not be true.

The Story
The first calls started about eight thirty in the morning. The initial call was from a friend of a friend who was driving through a small town about seven miles from Ithaca. “There’s a guy walking down the road with a yak. He’s got it on a rope like a dog on a leash and he’s got a big dumb smile on his face. I thought you should know.” I often got calls like this; updates on unusual happenings where someone saw something and they just needed to call someone. The next call was from the lone officer on duty in the town. He was running radar on the edge of town when he noticed an unfamiliar sight in his rearview mirror. “This knucklehead is walking up behind me with the strangest animal I’ve ever seen. I got out of my car and waved him over to the sidewalk. It turns out that he was at the livestock auction at the other end of town and bought a cow or steer or something called a Scottish Highlander. Damn thing has horns that are about six feet wide, and hair like bigfoot. When I asked him what he was doing with it, he said he was going to go to Ithaca and set up a petting zoo. He didn’t have ID or anything except a receipt for the cow. I called the Sheriff’s department and they knew him. His name is Keith Taylor. He’s been picked up a few times, all petty stuff, mostly noise complaints, disturbing the peace and some weird motor vehicle charge. He seems pretty harmless. He was on his way out of town, so I told him to stay off the road and be careful. I was glad to see the back of him. Sheriff’s dispatch said that you had been called a couple of times on him. Good luck!”
A year earlier I’d been called to the Sheriff’s department to help them with a man they had in custody. He’d been pulled over for driving 45 miles an hour in a 20 mile an hour school zone. When the deputy approached his car, the man began with “Do you know who I am?” The deputy was expecting a tale of local fame or high level connections. Instead he got an incoherent monologue that he referred to as “arble-garble.” At the time there was a suspicion of substance abuse. The police report stated that, “Mr. Taylor declined to take a field sobriety test and became quite agitated. When I suggested that he come with me to the sheriff’s department, he began to kick my car and curse. I then took him into custody.”
The deputy was frustrated. He met me at the sheriff department’s front door saying, “The guy can’t calm down. Maybe you can do something. All he’s got is a traffic ticket. I could charge him with harassment, but that is a huge pain in the ass for me. See if you can calm him down and get him out of here. I go off shift in a while and I don’t want to leave him behind.”
Keith was being held in a small corner interview room with glass on two sides. There was a rectangular metal table attached to the floor with a pair of metal chairs facing each other on either side. Keith saw me coming and stood near the door. The deputy pointed at the chair, “Sit!” Keith sat. The deputy unlocked the door and let me in. “I’ll come get you when you’re done,” he said and left.
Keith was a tall, thin white man, with a narrow face and crooked teeth. Even though he was only in his mid-thirties, he had a haircut like a fifties rock and roller, swept back on the sides with a big curl on the top of his head that hung over his forehead almost to the bridge of his nose. He had on jeans and boots and a western shirt with decorated pockets. “I’m Terry Garahan from the county mental health department. The deputy said you were pretty upset and thought I might be able to help. What can I do for you?” Keith gripped the table top with both hands, gritting his teeth. “Now I’m crazy! I can see where this is going. I’m Keith Taylor. I’m the man who is going to decide whether you keep your job or you move on. Understand? I might not decide your fate, but your fate will be decided by me. There are things that I know and things that you know, but I don’t think we know the same things or things that are the same. Understand?” The monologue continued for about twenty minutes with my few interjections of: “That sounds pretty difficult” or “I’m sorry to hear that.” I occasionally nodded my head in response to, “Understand?” with recognition of the fact that in listening to him, there were many things I did understand. I tapped on the glass for the deputy, and said to Keith, “We need to figure a way to get you out of here.” “Good stuff!” he replied.
After an hour on the phone, I had a story and a resolution. Keith was a local guy who was born and raised on a nearby farm. He’d joined the army right out of high school and was given a medical discharge for bi-polar disorder during his first year of service. He’d stayed in Texas, where he’d been stationed, until recently when he decided to return home. His dad said the Veteran’s Administration had been slow to transfer his case and he’d stopped his medications. Within half an hour his dad showed up and the deputy was happy for Keith to leave with him.
During the following months I got several calls about Keith from his dad. He either refused to take his medication or he took it and spit it out or took it and threw it up. Keith’s mom and dad had a small dairy farm a few miles from town and had their hands full. Keith was their only son and while they wanted to help him, they hadn’t really spent much time with him as a mentally ill adult. He’d been in Texas for fourteen years.
One early spring morning I drove out to the farm after an exasperated call from Mr. Taylor. I found Keith in a shop under the hood of an old, beat up Porsche with Texas plates. There was the number 11 formed by two long strips of duct tape on each of the doors of the car. The car was as loud as a jet plane with him revving it by pulling on the throttle. He looked over his shoulder at me. “This car, after I finish, will be the fastest car in the world.” “Your dad is worried about you!” I shouted. He replied, “The 11 is for the number of letters in my name.” He reached in and turned off the ignition, then leaned against the car, looking at me, saying, “A lot of people don’t believe in numerology. But if you think about it, it really makes sense.” I asked him, “Your dad doesn’t think you’re taking your meds. Are you?” He replied, “There is a lot of misinformation going around. Excuse me.” With that he got in his car and drove away.
About midnight that night, I got a call from the state police. Keith Taylor had been arrested and taken to the county jail. A trooper had been having a coffee break in a diner just outside the city limits when he heard the sound of a very loud car. He turned on his stool in time to see a flash of metal go by at high speed. He raced to his car and got on the radio looking for other available troopers or deputies in the area. Another trooper pulled over “number 11” about ten miles away after clocking it at one hundred and three miles an hour. “What is your problem?” Keith had asked the trooper when he tossed his license and registration at his feet.  Unfortunately, the problem was Keith’s; losing his license, car and spending nearly a week in jail.
Now, months later, I was preparing to see what new plan Keith had concocted.  I stopped to see one of the psychiatrists I consulted with. “Petting zoo! Really! He wants to open a petting zoo? Danger to self or others might be able to be met with the cow,” he said, “but I doubt it. Maybe you could trade the cow for three magic beans.”
I saw Keith about five miles outside of town. He was sitting in the grass on the side of the road. The cow was tied to a mailbox, grazing on the thick grass surrounding the wooden post. It was a beautiful animal, a movie star of cows. I drove past and turned the car around in order to be on the same side of the street. “Keith, how are you doing? What’s going on?” I asked. Keith lay back on the grass and closed his eyes. “The world is in turmoil. All I want to do is bring a little joy into the world. I grew up with cows. Kids should be able to see cows. But I’m so tired.” I stood over him blocking the sun. “Keith, you don’t look well. You are really pale and you’re sweating. Are you faint?” “I don’t feel so good,” he responded. “I think you need a doctor to take a look at you. I’m going to call someone to come get you.” The ambulance and the deputy showed up together. The emergency medical technician, after looking at Keith, conducted a simple test, pulling on the skin on his wrist. “He’s really dehydrated. No wonder he feels so lousy.”
The Scottish Highlander was tied to the rear bumper of my car when the deputy pulled away. “I’m glad I’m not you,” he called out the window. It was almost six in the evening when the livestock truck came to get the cow. They came shortly after I received a call that Keith had voluntarily admitted himself to the mental health unit at the hospital.
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, October 6, 2011

Dementia, when ignored, may have deadly consequences.

Mental illness and mental health are part of our overall health concerns throughout our lives.  As our society becomes more fragmented, we must remain aware of those who have few relatives or friends. It is estimated that in the United States there are over five million people with Alzheimer’s and many more who have other forms of dementia. How we help them says a lot about our society.

The Story
                Muriel Davis was 78 years old when her husband Ray died. They had been married 60 years. Ray had spent his entire work life at a company that made timing chains for car engines. His cancer had been a long drawn out affair that caused heartache and cost a good deal of their savings. Muriel acknowledged the pain of her husband’s death by being constantly reminded of their only son’s death in an automobile accident many years earlier. 
                Muriel didn’t experience loneliness in any specific way. She and Ray had lived a fairly quiet life.  She’d spent nearly twenty years serving food at the hospital cafeteria. Her work friends had never been to her home and when they gave her a retirement party at a local restaurant, it had been Ray’s first time meeting them. When Muriel and Ray were in their forties, after Ray Jr.’s death, they’d attended church and joined a bowling league. The demands of both proved too much. One winter they “forgot” to join the league and also avoided the phone calls of a pushy pastor. When retirement came at age 65 they focused on their home. Ray built a garage and made small repairs. Muriel worked in her garden and made preserves. Winter months were spent in front of the TV.
                The house was a small white farm house a few miles outside of the city of Ithaca. When it was built in the 1850’s, it sat in a grove of trees 100 feet from a dirt track where people walked, rode horses  or drove wagons, beginning their decent into the valley where Ithaca and Cayuga lake lay. When I first visited, it was seven years after Ray’s death. The house was thirty feet from a busy highway where cars and trucks roared by at sixty miles an hour. Sumac and other scrub trees hid most of the front of the house, while a partially dead maple tree threatened the detached garage. I climbed the uneven front steps to a six by eight foot enclosed porch. Battleship grey paint chipped and peeled under my feet. Ripped plastic, an earlier attempt at winterization, snapped in the fall breeze all around me.
                I rapped with my knuckles on the door. “Mrs. Davis, Mrs. Davis? It’s Terry Garahan. I’m from the county and I need to talk to you.”  My voice was raised to overcome the sound of traffic and what I assumed was a TV blaring in the living room. No response. “Mrs. Davis, Mrs. Davis. Can you come to the door please; I need to talk to you.” My voice was just short of a yell.  I could hear movement in the room behind the door. “I’m sleeping. What do you want?”  A scratchy older woman’s voice said.  “Mam, I need to speak to you, can you come to the door please?”  “Hold on, hold on, I’m going to be a minute. “ Moments later the door opened to reveal a short broad woman with thinning white hair. She had on a faded, flowered housedress, orthopedic stockings and bedroom slippers. I tried to peer around her, but her body blocked most of my view.
                “What do you want?” she said cautiously. “I’m from the county and I need to talk to you, do you mind if I come in, it’s awfully noisy out here,” I said referring to the trucks passing by. “I don’t know. This isn’t really a good time,” she replied. “It’s really important that I talk to you today,” I continued. “Oh all right,” she said, pulling the door open. “Come on in, but be careful, I haven’t had time to clean.” I held the door and watched her wade through knee-high trash to a fake leather recliner.  She turned and sat, pushing back hard to elevate her swollen legs. Oprah spoke loudly from the television three feet in front of her. The door slammed behind me and I found myself in a swamp of Styrofoam containers, paper cups, plastic lids, brown paper bags and bits of food.  I took a step and noticed movement along the floor under the mess. Things scurried for a moment and then stopped. I took another step and it happened again. “I suspect you’re here about the plumbing. I knew somebody would finally show up. The bathroom is there,” she said, pointing to a partially opened door where the tide of trash seemed to dissipate.  I steeled myself for my brief passage across the room. Ripples of movement preceded me as I carefully raised my feet above the rubbish seeking a safe place to step. As I got to the bathroom door I turned and took in the scene.
Standing on the edge of this sea of trash I was able to confirm the call I’d gotten earlier in the week. A young Hispanic man had called to tell me about an older woman he was worried about.  He was the delivery man for a pizza and sub shop downtown. He’d worked there for about a year and delivered to Mrs. Davis four or five times a week. She’d also made a separate arrangement for him to pick up wine for her at the liquor store once or twice a week. “I’m worried about her. She seems to be really losing it and her house looks like a horror movie.  I tried talking to social services and they told me to call you. They think she might be crazy.”
The assault on my senses reached a peak with the smell of the bathroom. Feces and urine filled the toilet to the brim. The seat was smudged and cracked. The sink was a brown stain of iron from the well water. The bathtub was filled with dirt and dust. I tried the sink faucet. Nothing came out. “Mrs. Davis, there’s no water in here.  Do you know why?” “The well pump broke a while ago. Aren’t you here to fix it?” she responded. “Do you mind if I look in the kitchen. I want to check the sink in there.  Is that all right,” I asked. “Sure, help yourself,” she replied.
The counters and sink in the kitchen were filled with dirty dishes, pots and pans.  Empty wine bottles littered the floor and pantry. Near the back door was a five gallon paint bucket with a toilet seat on top.  It was nearly full. I peeked out the back door and determined that Mrs. Davis had dumped many other bucketsful onto the back steps. 
I went back to the living room to see what else I could learn. I waded through the mess trying to ignore the critters under foot. “Could you turn off the TV for a minute? There seems to be a real problem with the plumbing,” I said.  “Ray’s going to fix it when he gets home.” Mrs. Davis answered, clicking off the TV with a remote. Up close, I noticed the sores on her legs and the immense swelling around the ankles.  There was also a rash on her arms and what looked like blisters on her chin that appeared to be filled with pus. “Mam, you have some sores there”, I said pointing at her arm.  “Do you have a doctor? Has anybody taken a look at those?” “I see Dr. Spanger. She’s always treated me real good.” She replied.  “Mrs. Davis, I know you live alone here, but does anyone come in to help?”  “Her watery blue eyes stared at me. “Why in god’s good name would I need help?  I’ve lived in this house almost seventy years and I think I’ve done all right by myself. I forget, why are you here?  The cable’s fixed, see?”  She clicked on the TV just in time to see Oprah giving things away. “Mrs. Davis, I’m going to leave now.  I’ll be back in a little while. Are you going to be OK?” “Could you get me some of that Lambrusco wine when you come back?” she asked.
I went back to my office and called Dr. Spanger.  She said her office had been trying to get Mrs. Davis in for at least six months. She’d even arranged transportation.  When the appointment time came Mrs. Davis hadn’t answered the door. When I explained things, the doctor let out a sigh. “I knew she was demented, but I hadn’t thought it was that bad.” I signed the paperwork and arranged for the Deputy Sheriff and ambulance to meet me at a gas station nearby and informed them of our goal.  “She’s a nice old lady, but spirited. The best thing we could do is walk her out. Believe me; you don’t want to drag your gurney through that mess.”
The EMT’s and the deputy waited on the lawn.  I went up on the porch by myself and banged on the door a couple of times. The TV was still blasting. “Mrs. Davis, it’s me, Terry Garahan. I was here a few hours ago.” I pushed open the door and started to enter.  Mrs. Davis was leaning back in her recliner. In her right hand was a pistol. “What do you want? Get the hell out of my house.  I don’t want to have to shoot you!”
I pulled my head back behind the door. “Mrs. Davis. I’m from the county. I was looking at the plumbing. Remember? Could you put the gun down please?"  Behind me, the Deputy unholstered his weapon. Mrs. Davis waved the gun around for a minute and then set it on a table next to her. “Judge Judy’s on.  I like her!” she said to the TV. Moments later the small room was filled with the Deputy and two Emergency Medical Technicians.
When I visited her at the nursing home the next week she sat on a soft sofa next to another old woman watching an episode of Judge Judy.
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.