Psycho Therapy
Prologue The first year of medical school was purely classroom and lab: anatomy, neuroanatomy, physiology, and biochemistry. No patient contact. The second year included pathology, microbiology, pharmacology and similar with limited patient contact. Everyone was eager to get to the real stuff: junior and senior years on surgery, internal medicine, obstetrics and pediatrics in the clinics and wards of Parkland Hospital. I enjoyed it so much that clinic duty and studies was more entertainment than work. The thrill so energized me that I began to cast around for outside work that involved patient contact. One opportunity looked especially appealing, a job as an “extern” at Timberlawn, a private psychiatric hospital.
“You’ll love this job,” one of the previous externs told me. “They leave most of the night and weekend exams and calls to us. The psychiatrists don’t want to be bothered, and it’s not like the patients are really sick, they’re just crazy. And they’re locked up, too. How much trouble can they be? How much harm can you do? When in doubt I just give ‘em a big shot of Thorazine,” he added, referring to a new antipsychotic drug. “It knocks ‘em down until morning when the real doctors show up.”
On the strength of this dubious endorsement I signed up to work my last two years of medical school as a paid extern at Timberlawn Psychiatric Hospital, a prestigious private institution, now defunct with most other psychiatric hospitals. I was one of a team of three medical students who shared call doing after-hours and weekend admission interviews and physical exams. During the summer, when medical school was not in session, I worked daytime making rounds, attending staff meetings, and doing physical exams and medical histories on new admissions.
1961, Timberlawn Psychiatric Hospital, Dallas
As a budding physician-to-be I relished the evening hours at Timberlawn because when in call I was the go-to guy if the nursing staff needed help and didn’t want to bother a psychiatrist. In those two years I saw a textbook’s worth of interesting patients and came to admire psychiatrists. They seemed sage, caring, and majestically above the foibles that roiled the lives of their patients.
I enjoyed it so much that I began to think about being a psychiatrist—human behavior interested me, and I could be in the middle of it as a psychiatrist. But there were other choices. I liked pathology, too. I made good grades in pathology the previous year. I liked the cool, detached rhythms of the laboratory. Pathology or psychiatry? Both had an analytical quality that appealed to my desire to know how things worked.
Madelyn was a long term inpatient with severe schizophrenia whose very high monthly bills were supported by a trust fund. She was completely out of touch with reality, alternately muttering gibberish and talking to unseen friends and tormentors, all the while twisting her face and contorting her body into strange shapes. I watched her closely.
One day Madelyn and her psychoanalyst strolled by hand-in-hand on a walk around the grounds.
“Wooahwu, no Billy. Not! Shmooroyah, uh, gromany. No! No!,” Madelyn spluttered and stamped her foot.
“Yes,” the analyst said. “Hm, hmm. Go ahead.”
“What the hell,” I said to myself. “This is crazy.” Pathology leaped ahead of psychiatry.
To be fair, this was in the days before a wave of more effective psychoactive drugs emptied mental hospitals and bankrupted Timberlawn. Talk therapy and a few drugs were not the only therapies available. Electric shock treatment (EST, aka electroconvulsive therapy, a, uh, less shocking term used by fussy professionals) and insulin coma were mainstay treatments for depression and paranoia.
EST induced epileptic-like seizures by loosing a surge of voltage through the brain.
Insulin coma therapy required injecting a horse-size slug of insulin to lower blood glucose enough to induce coma, during which a seizure, if one occurred, was a bonus. Both were wildly beyond anything I had imagined about psychiatric treatment, so I inquired about their scientific basis. “It works . . . some of the time” and “It’s about all we have” captures the gist of it.
Patients were amnesiac after treatment. We joked that they were improved because they couldn’t remember who they were, why they were there, or what we had done to them.
EST patients were led into a small windowless room, which looked less like a place of healing than an execution chamber. They were escorted by their psychiatrist. Trailing was a knot of burly male attendants in white uniforms. The message was clear—this deal is going down. A somber clutch of doctors and staff waited beside a white-sheeted gurney, big leather straps dangling. Attendants lashed down the patient with speed and choreographic precision that would do honor to a NASCAR pit crew: arms spread wide for an intravenous line on one side and blood pressure cuff on the other, ankles bound tightly together. The crucifixion pose was not lost on anyone.
Most patients came quietly, either because memory of their last visit had been erased or because they’d been emotionally neutered by chemicals, otherwise known as tranquilizers. The terrified and the reluctant were soothed by a psychiatrist, a trusted advisor and confidante, which seemed a betrayal of the bond psychiatry purported to be at the core of the psychotherapy: therapist-patient relationship.
The most troublesome were usually paranoid schizophrenics who saw the scene as delusions come true—the world really was out to get them. Combative ones were overpowered and injected with a short-acting sedative, which melted frantic struggle into limp aquiescence.
I stood to one side until the stage was completely set. At the last moment it was my job to step forward and insert between the patient’s jaws a wooden tongue depressor bandaged thick with cotton surgical cloth, the better to prevent them from chewing tongue into hamburger. On my first case, just before flipping the switch the psychiatrist gave me this final advice, “Keep your fingers out of the way.”
As the psychiatrist squeezed the patient’s temples between electrode paddles, I imagined him as Dr. Frankenstein stepping on the switch connected to a big black box studded with dials, lights, and switches. In an instant the patient was galvanized by body-wrenching bucks and leaps as the current coursed through tender brain cells, whose tiny native electrical currents were overwhelmed by a tsunami of electrons racing through. Amazingly, it worked most of the time and is still in limited use.
Inducing insulin coma, now gone along with prefrontal lobotomy, leech cures, and other discarded practices, was straightforward and deployed en masse to an entire wing. The patient received a horse-size dose of insulin, which in short order crashed blood glucose to coma level. The brain requires glucose. When it doesn’t get enough cells stop working. The first fires to flicker out are the higher functions: consciousness, thinking, emotions, and so on. More primitive functions, like breathing, are less sensitive. The trick is to drive glucose down, but not too far. Coma yes; respiratory arrest, no.
For safety’s sake and to ensure docility, before injecting insulin we wrapped and taped them, mummy-like, in a sheet leaving head, feet and one arm exposed for injection. Then they were buckled into place with leather straps. Sometimes they had seizures, considered a bonus as long as they didn’t vault of out bed and crack their skull. Insulin was injected into the open arm, which was then wrapped and taped to make the mummy complete. We watched as they sank into coma, zombies who lightly disturbed the eerie silence of the hall with a foam of sighs, burbles, and snores.
After an hour or so we brought them back to life by injecting intravenous glucose, the psychiatric equivalent of a bartender’s simple syrup, and difficult to do correctly because it was syrupy thick and required a big bore syringe and needle, sometimes bigger than patient veins could accommodate.
One especially memorable patient was a paranoid schizophrenic I had been following for several weeks after her admission to the lock-up ward, a domicile reserved for “the craziest of the crazed,” as we were fond of saying. Some paranoids are furtive and keep their delusions to themselves. This woman, however, was loud and combative: radio waves were reading her mind; the staff was engaged in a plot to drain her bank account, a not so delusional thought; and voices no one else could hear were tormenting her unmercifully. But this behavior had abated somewhat, and she had been “promoted” onto the insulin ward.
She was snoring contentedly, the fires of paranoia snuffed for a while, maybe. I loosened her restraints, and unfurled the sweat-soaked sheet to free an arm for the glucose necessary to relight the fires of consciousness. Finding a good vein was important and tricky. Women tend to be more difficult than men because their veins are smaller and obscured by the layer of skin fat that is usually thicker in women. I jabbed at a faint blue thing that looked like a vein, pulled on the plunger to see if I could draw blood as proof the tip of the needle was in the right place. I got a little. Maybe enough glucose would get in to do the trick. I pushed on the plunger. A knot swelled at the tip of the needle. I was out of the vein and had succeeded in bringing her only halfway awake. She was sleepy and disoriented, but able to follow instructions. It was necessary to finish the job with orange juice. I unfurled the sheet and raised her to a sitting position on the side of the bed. She looked around, silent and uncertain.
“Mrs. Krankle,” I said in my most soothing tones, “you’ll feel so much better if you’ll have some orange juice.”
I held the glass out to her. She took it and glared at me with a doubtful stare.
“I don’t know,” she said, studying the glass, suspicion written in her frown.
“It’s okay,” I said. “It’s just orange juice. I made it just for you.”
Suppressed paranoia, molten hot, bubbled up from the depths of her psyche and spewed from her lips.
“You sonofabitch,” she said and threw the juice into my eyes.
It stung like hell. While I was busy trying to regain sight, she grabbed my tie and cinched it tight around my throat. She was surprisingly strong. We battled for a moment before I croaked a call for help and was rescued by a nurse.
She was un-promoted back to the lockup ward. I switched to clip-on ties.
Epilogue Poor Madelyn was still there when I graduated and left Timberlawn. That someone so disturbed was being offered “talk therapy” reflects how little psychiatry had to offer many patients in those days.
Insulin coma treatment disappeared a few years after my term at Timberlawn. It’s a wonder we didn’t kill someone or render them brain-dead.