Back Ward
When I began my new job as the director of a large State Hospital inpatient unit I thoughtthat I was prepared for anything. Like many young physicians I was idealistic, energetic,
and pretty filled up with myself. I had received wonderful training at a prestigious Ivy
League mental hospital and had taken a special interest in the care of people with chronic
schizophrenia. Two years of experience with acutely disturbed patients at a busy county
hospital and a year of working at an HMO clinic had, I thought, fully rounded out myclinical experience. But nothing could have prepared me for what I was about to become
immersed in.
My new Unit was what used to be called a “back ward”. Most State Hospitals of the time
had them. These were places for patients that had to be confined indefinitely, usually due tothe severity of their symptoms or a history of behavioral problems which would make areturn to community living impossible. The name comes from the fact that these wards
were usually located in parts of the hospital that were as far away from the other patientsand the eyes of visitors - as possible. We had forty-four patients on The Unit and they had
stayed there anywhere from one year to a high of 48 years. In the first two years that I
worked there the average person who was discharged had been on the ward for over eight
years.
The atmosphere of this place is hard to describe in words. “Crazy” or “chaotic” are fitting
terms but hardly begin to do it justice. Perhaps “jaw-dropping” comes the closest. There
were severely psychotic people everywhere. Everyone was doing and saying crazy things.
Violent altercations were an everyday occurrence. As I listen to tapes I made back in those
years, though, it is the sound of the unit that is so striking. Patients were constantly yellingat each other, screaming out insane gibberish, or moaning in despair. In my therapeutic zeal
I had insisted that my office be located right on the ward, so these sounds were a constantpart of my life. I soon learned what noises spelled trouble and which could be safely
ignored. Over time I even became able to identify patients by their knocks at my door.
Drawing on my experiences in training at a hospital that had always been at the forefront of
the “ humane treatment of the mentally ill ”, I quickly set out to make some changes. I tried
to see each patient each week, alone, for a decent length of time. Since I wanted the patientsto address me as “Doctor Turnquist” it only seemed fair that I would address them by theirtitle and last name as well. They had always been referred to by their first names
previously and that relationship imbalance had never been questioned.
Other changes included trying to give each person as much freedom to come and go as they
could handle. If it was necessary to deny them this privilege we tried to explain why thiswas done and what they would have to do to regain their rights to freedom. The intake of
caffeine had been totally prohibited (for patients - not for staff) for the entire hospital formany years. The staff had been convinced that the patients would become violent if allowedto drink coffee. A successful campaign was launched to restore the right to drink coffee tothe patients.
Perhaps most puzzling to the long - time staff members was the attitude that psychotic
symptoms, no matter how bizarre, contained some effort on the patient’s part tocommunicate something. To express some part of themselves, some hidden wish or fear
perhaps, that they could not deal with in any other way. Over time a new attitude emerged
among many of the staff members. They began to look at the patients with increased
curiosity and tolerance. Eventually the ward’s atmosphere began to include the sound oflaughter.
The previous psychiatrist on the ward had not seen things in quite the same way. The
majority of the patients were taking very large doses of the powerful antipsychotic Haldol.
They usually received that by monthly injections, along with lithium and Tegretol (an antiseizure drug that was typically given for behavioral control) by mouth. Many of thesepatients were experiencing tremendously uncomfortable side effects from their medications,and those side effects, e.g. restlessness, agitation, apathy, confusion, etc. were usuallyinterpreted by staff as symptoms of the mental illnesses themselves.
Setting out to minimize medication exposure, eliminate side effects, and simply keep people
as physically comfortable as possible went a long way towards building good relationships
with my new patients. Listening to them was helpful in this regard too. Many especiallyliked my belief that we could both teach each other things. I was fortunate to find so many
people who were willing to try to explain to me what their mental illness was really like forthem, to let me into their internal world. The education that they provided was truly
invaluable.
Of course everything did not go smoothly. As psychotic people will do, some people
distorted their representation of me in all sorts of ways. Many reacted to me as though I
was a sadistic tormenter, regardless of how kind I tried to be to them. And my one
unpardonable sin was that I had been given the charge of eventually discharging thesepeople from the strange but familiar place that had been their home for so long.
What follows will be an attempt to tell the stories of some of these people, to provide someinsight into what this ward was really like. Things have changed in the ensuing years.
Better medications are now available to reduce psychotic symptoms in people who had
previously been unresponsive to any treatment efforts. In our present budgetary situation
we no longer can afford to house patients in expensive hospitals for decades on end. The
community has become at least a little better at providing care for some of these folks. A
ward like this one may never exist in quite the same way again.
Needless to say, the identities of these individuals will be disguised. I will use invented firstnames for them and change any facts that could lead to their identification. Many of theelderly patients, and some of the younger ones, have been dead for years now anyway.
Strangely enough, though, I think that few of these people would have objected if theiridentities had been made known. As bizarre and seemingly different from other humans asthese people were, many had a wonderful heart underneath it all. Most would gladly dowhat they could to improve our current mental health system or to bring a chuckle to those
who study it.
A famous psychiatrist named Elvin Semrad was once asked “how do you help yourschizophrenic patients to recover?” Semrad replied, “Why you fall in love with them, ofcourse”. By those standards I clearly failed these people miserably. Most of these patientsthat I will describe came to have somewhat better lives over time, I think. All of them were
eventually able to leave the State Hospital. But very few experienced any sort of complete
recovery from their illness. While I’m sure that I did not love any of these people enough, I
hope that the glimpse into their inner worlds that follows will be, at least, a loving andrespectful one.
You Couldn’t Make This Stuff Up
Lois was 72 years old when I met her. She had spent the last 12 of them on The Unit.
She had been an attractive woman in her youth but decades of schizophrenia and theattempts to treat it had changed all of that. She was quite overweight from the starchy
hospital diet and the medications that made her so hungry. She only bathed in response
to a show of force. Her hair and her eyes were wild. Like many State Hospital patientsof the era, all of her teeth had been removed. Sometimes this was done to control biting
but more often, as in Lois’ case, it was simply cheaper and quicker to deal with infected
teeth by removing them entirely. The image that Lois presented was, quite literally, akinto the picture that comes to mind when children think of “witches”.
Occasionally psychiatrists encounter memorable patients that seem to embody every
symptom that the Doctor has ever learned about- and more. Lois was clearly such apatient. Her incessant screams were typically driven by genuine terror. Oftentimes shewould lay on the floor of public areas and yell about the terrible things that were being
done to her. This was particularly common if visitors were on The Unit. When nurses
tried to move her to a bed or quiet room she would go completely limp, resulting infrequent back strains among the staff. Very few of the staff were kindly disposed
towards Lois. She never appreciated anything that they tried to do to help her. To makematters worse, there were no single rooms on The Unit. And Lois had a particulartalent for getting her roommates stirred up. It quickly became apparent that the staff
were going to look at the ways in which I dealt with Lois as the ultimate test of whether
all of my new ideas actually had any merit to them.
Lois reluctantly agreed to come to my office during my first day on the job. Her room
was right across the hall from me so it wasn’t a long walk. As respectfully and gently asI could, I invited her to meet with me so that we could get to know each other a little bit.
I explained that since I was going to be her new psychiatrist it would only make sense
for me to know her so that I wouldn’t make mistakes out of ignorance. I was quite
encouraged when she agreed to meet with me as she had always refused to meet alone
with anyone.
Within moments of sitting down in my office she made it clear that she “already knewme”. She explained that she had been “found in a garbage heap” and begged me not toread her mind. When I tried to protest that I did not have mind reading talents but
thought that my job would be tremendously easier if I did her demeanor shifted.
“You’re just a little quack Doctor” , she snarled. “You’re the one with the long black
tail. You saved the witch and you wouldn’t save me . Now you’re breaking up
everything inside of me and making me change into all colors. Some Doctor you are. I
will never meet with you again”. With that she stormed out of my office and it was
several weeks before I could persuade her to return. Her screams and crazy statements
only increased. The nursing staff was quickly convinced that all of this talk about“understanding people” was only, as they had suspected, going to make all of the
behavior problems on The Unit get worse, and that their firm way of dealing with Lois
had been the only way possible.
Eventually Lois did return to my office and, over time, she gradually began to reveal her
inner world. The fragility of her sense of self was overwhelming to observe. She really
could not tell where she left off and the outside world began. Like many people withschizophrenia, she had difficulty distinguishing between the three great classes ofthings: Human, Alive But Not Human, and Inanimate.
Lois often complained about her bed. Many times she would go for weeks sleeping on
the hard linoleum floor. She believed that her bed was becoming smaller and smaller
and that it was able to read her mind. She believed that “two men with poles lived inside
her mattress”. Once she revealed that she had “an Anastasia bed”. Such a bed could
take her to different places and times, without her awareness or control, only to “dumpher off”. Perhaps most terrifying was her belief that she was actually “becoming herbed". She meant this in the most literal way.
It turned out that much of her aversion to bathing resulted from the terror that she
experienced when forced to shower. She complained “if I go into a shower I may never
be able to get out of it”. Similarly, she was afraid of pots, pans, and other cooking
utensils. She always feared that kitchen equipment “could cut her legs off”. She
believed that some sort of “thing” lived inside of her and controlled all of her
movements.
Her lost beauty figured prominently in Lois’ delusions. One morning I heard abloodcurdling scream that was of unusual intensity even for her. When I rushed overto her room, thinking that there must have been some sort of fight, I found her on thefloor sobbing. She pointed to her legs and said “someone came in last night and cut off
my beautiful legs- they replaced them with these fat ugly ones. You have to dosomething”.
Lois believed that the nursing staff had a special machine behind the nursing station.
The only purpose of the machine was to “make patients homely”. She was absolutely
convinced that the nurses were jealous of her because of her beauty and took all sorts
of steps to destroy her appearance. She would wail “ I was so beautiful -now they've
turned me into this stretched out old thing”.
One of the old conceptualizations of schizophrenia took special note of patients'“ambivalence” - their inability to decide between two opposing views of things. This was
especially notable in her relationship with me as it developed over time. The dreadfulaccusations never did go away completely. “You just electrocuted me you fucking
bastard … You just tapped into my water supply!” she'd complain. Eventually the otherside of her feelings for me began to surface, often in odd metaphorical ways.
Once when I came into her room to invite her to my office she asked “aren’t you afraidof burning up in here?”. She refused to come to my office on one occasion because“there are too many drills in your bed”. As she began to become more connected withme I commented once that “she seemed to have trouble deciding whether she wanted alover or a servant”. With a lewd smile she responded “ well, I’d like both”.
In keeping with my inflated view of myself back then I , like most humans, believed that
I was probably pretty good looking compared with the average person. So I was a bit
taken aback when she looked at me sincerely one day and said “ You know, I’m reallysorry about the way you look- I like you anyway, as a person”. She suggested that I
should find out what medicine she was taking and take that so that I could "become alittle better looking.”. Another time, immediately after a barrage of complaints about
how I “turned people into hamburger” she paused, cast a knowing glance at my crotch,
and smiling a toothless grin said “ I’d be happy to suck that for you”. Thanking her for
her "incredibly generous offer" was difficult. Sometimes people say things that are sohilarious and unexpected that it's pointless to even try to keep from laughing.
Returning from a walk one time she smiled sweetly and said “ Be careful, we might fall
into each other’s arms’’. One of her cleverest attempts at seducing me came the day shewhispered “you know, my brother owns a rubber factory”. I was touched one day whenI met her usual stream of indefensible accusations by gently asking her “what is it thatyou really believe that I’ve really done to you?”. For just a moment a tear came to her
eye as she replied “you married someone else”.
Like many severely psychotic people, Lois had a number of theories about what had

happened to leave her in such a state. She believed that she had come from awonderful, caring family. Her father was described as “the richest person in the world”
and “the Heavyweight Wrestling Champion of the World”. She thought that something
had happened to her at about the age of 17 that had changed everything. My attempts
to educate her about the onset of schizophrenic illness seemed to go nowhere. Her
theory was that she had been “adopted by Adolph Hitler” and later “kidnapped to theNorth Pole”. At times she was convinced that Satan lived inside her or that she had
married him. Once she revealed that she was “stuck in a movie that never stops”. She
insisted that she “needed a new head” and that her existing head was going to fly away
entirely. Sometimes her strange experiences were attributed to “the rays that come up
through the floor and go right through me”.
Whether it was due to our work together, the reduction in her medications, a better
environment, or other unidentified factors, Lois eventually became much more pleasantand “manageable” on The Unit. Most of the screaming behaviors stopped and she
began to talk with other people in more rational ways. Of course this “clinicalimprovement” brought with it the new threat of discharge from the hospital. She was
not enamored with the idea of leaving. She said that she’d be happy to look at otherplaces to live- right after I had all of the buildings on our large hospital campus painted
orange. Once, in a candid moment, she protested that she could not possibly go to anursing home to live because she “ would have to act up too much to get attention”. But
she was finally discharged to a community nursing home anyway and never returned. I
was genuinely sad to see her go.
Mark was one of the “wandering paranoids” that would come through our systemevery now and then. These people always believed that their demons were a part ofexternal reality, rather than a personal creation that they would always carry with themwherever they went. They assumed that if only they could find that safe place where
their tormenters could not find them they would be OK. In Mark’s case that safe place
was hiding under a stairwell at the airport. When security officers discovered him he
was wearing only a pair of sox. Huddling in an airport stairwell wearing just sox will
get you a psychiatric evaluation nearly anywhere. It was hard to maintain mycomposure when he revealed that he was fleeing “Richard Nixon and Valerie
Bertonelli" (a now obscure actress who had once starred in a show called "One Day At
a Time"). Apparently the two were in cahoots and had been chasing him for years.
They each spoke to him in a threatening manner. Sometimes their voices would merge
so he couldn’t tell which was which. At times Mark was forced to conclude that Mr.
Nixon and Ms. Bertonelli were actually one and the same person.
Selma's appearance was unusual, even by The Unit's standards. She always walked in
an odd, hunched over fashion. Sort of like a bad Groucho Marx imitation. But Selma
did not take on her strange gait for laughs. She sincerely believed that she was carrying
Satan on her back. It looked like he was quite heavy. She had always tried to get out of

her required yearly physical exam but one year the nursing staff persisted and she
reluctantly consented to be examined. The physician was amazed to find that she had
two imitation pearls jammed deep into her ear canals. They seemed to have been there
for a long time, perhaps years. When asked why she had the pearls in her ears Selma
explained that they were "hearing aids".
Strangely enough, those pearls might have been hearing aids, after a fashion, for Selma. A
common symptom among people with schizophrenia is "hyperacousis". In this condition
ordinary sounds can be experienced as though they have been amplified manyfold. Even aquiet sound that is barely perceptible to others may seem incredibly loud and unnerving. So
perhaps the pearls were just what Selma needed to survive on the noisy Unit. But thenagain, she might have been becoming hard of hearing and actually believed that those pearls
would help. She never would explain how those things worked.
Monty was a man who was brought in after what was assumed to be an unsuccessful
suicide attempt. He had jumped off a bridge that crossed the Mississippi River. People
die jumping off this bridge nearly every year but somehow Monty had survived. Of
course we tried to determine what would prompt him to do such a thing. It was aconflict over cigarettes. Cigarettes are the most important thing in the day to day lives ofmany people with severe schizophrenia. An aid at Monty’s nursing home had
threatened to take his cigarettes away if he didn’t correct some behavior or another andit was more than Monty could stand for. Amazingly, Monty consistently maintained that
his several hundred foot jump into the Mighty Miss was in no way to be understood as
an attempt to kill himself. Far from it. This was a part of his new plan “to live
underwater”. He said that he had it all figured out. He would have unlimited water todrink and plenty of fish to eat. There would be no meddlesome staff members to answer
to. He became very annoyed, however, when I gently asked how he was going to smokein his new home. “You Doctors are all alike” he snarled. “You all think that jumping
off a bridge is some sort of big deal”. Years later I was sad to learn that Monty had
drowned after wading into a different river. Apparently some ideas are just too good tolet go of.
Marie was convinced that she came from a long line of "Russian Nobility". She knew
beyond any shadow of a doubt that she didn't belong on The Unit. She "wasn't likethese people". Marie had been committed after throwing her television out the windowof her seventh floor apartment. As often happens in schizophrenia, the people on TV
spoke directly to her. Every sentence carried a special meaning for her alone. And thatday she just didn't like what they had to say.
Leonard might never had come to psychiatric attention if he hadn't started calling his
local police station asking them to leave him "a wake up call".
The clientele on The Unit had trouble adjusting to the new telephone system. Previouslythere had been two old fashioned pay phones that required a dime to make a call. Backthen the public rate was a quarter but the hospital had tried to give the patients a breakby keeping the cost down. Of course, even that dime was a hardship for many of our
folks so we were delighted when the pay phones were replaced by two new "princess"style phones that would allow local calls to be made for free. Within a few days,
however, one of the new phones was inoperative. Before the phone company was out to
fix the first phone the second one had died as well. The telephone repairman was
surprised to find that each of those phones was filled with dimes. Since there was nolonger a slot to put the dimes in people had jammed them into the opening next to thelever that the handset rested on. We had to put up signs saying "No Dimes Required"after the phones were repaired.
Benny was another man who totally lived for his cigarettes. He had lived on The Unit
for over six years by the time I met him. In those days cigarettes were generally doled
out on the quarter hour, for those lucky enough to have them. Benny would smoke his
cigarette in the smoking room- which was usually so dense with smoke that actually
having a cigarette seemed almost unnecessary- then immediately get in line for his next
cigarette. Like many of the patients he was taking a large dose of long-acting injectable
Haldol each month but was having a hard time with it. His entire body shookincessantly and he could rarely sit still for more than a few moments at a time. He could
not light a cigarette on his own because of the tremors - the nurses always had to do
this for him. It had been over a year since he had stepped foot off The Unit. Of course
we felt that he was severely addicted to nicotine and speculated that he also smoked somuch because he was extremely nervous and this was his best chance of relaxing for aminute or two.
We didn’t know back then that cigarette smoke increased activity in the liver enzyme
system that was responsible for breaking down Haldol. So Benny's smoking was also
driven by his unknowing attempt to reduce the level of Haldol in his bloodstream and theuncomfortable side effects that he was experiencing from it.
Back then the McNeil Corporation that manufactured Haldol was trying to advance the ideathat their product was far superior to everything else. A “pure dopamine blocker” theyclaimed, plus the convenience of once monthly injections. They had hired a couple ofnationally known shills- a psychiatrist and a psychopharmacologist who are still prominent
in the field today - to make the rounds of the State Hospitals explaining why Haldol was
the best thing that we could offer our patients. The only place for Haldol’s older
competitors was "on the pharmacy shelf ", the psychopharmacologist boldly stated when he
met with our medical staff. Of course similar claims had been made for centuries about allsorts of other wonderful treatments for schizophrenia but we still fell for the claims backthen. And the process still goes on with each new drug that is released.
It would have been hard to convince Benny of the wonders of Haldol. He wastremulous, stiff, and severely restless. He suffered from constipation, dry mouth, andwas having trouble urinating because of the side effect reducing meds that were given
along with the Haldol. To add insult to injury, he was every bit as psychotic on the
Haldol as he was without it. The only discernable “benefit” was that he was more docile
and manageable on The Unit than he had been in the community. He had no prospects
for ever leaving The Unit unless something changed significantly.
Benny was slowly switched over from Haldol to a modest dose of Serentil- one of thoseolder antipsychotics that “belonged on the shelf”. I learned that he had enjoyed playing
pool back before the onset of his illness and eventually persuaded him to accompany me
to a distant building on The Campus where we had an old pool table. His game waspretty terrible by then. I began to assess his clinical condition by whether he could
remember if his balls were the “stripes” or the “solids”. I’d know it was a bad day for
Benny if he neglected to remove his heavy winter gloves while we played. Over time weformed some sort of relationship but it was hard to say just how this looked from hisend. He did begin to look forward to our games and even requested them at times. His
side effects came under much better control and it was a big day for him when he could
finally light his own smokes again. He began to spend time in the day room watching
television with other patients. This does not imply that his schizophrenia had gone away
though. He was still terribly anxious and much of what he said did not make sense tous. When he was upset for one reason or another he would voice his displeasure byurinating on the floor outside my door. The slope of the hallway always brought theflow right into my office. In those days it was a common occurrence for me to come towork and notice that “The River Benny” had overflowed. A visit to the nurses station tofind out what had upset him usually followed.
Benny was afraid to leave The Campus to look for another place to live. Eventually wewere able to locate a half-way house in his home community that was willing to take alook at him. In order to persuade him to “interview” at the facility I had to agree to drive
him there personally. We brought his belongings and arranged for him to be able tostay if the interview went OK. The drive of over a hundred miles was agony for both ofus. He never said much of anything that I could decipher and I doubt that mycomments registered with him much either. Saying goodbye was hardly a “Kodak
Moment” but as I made the long drive home I suspected that we would each miss eachother in our own ways.
Scientists are trying to understand the powerful link between schizophrenia and smoking.
An estimated 90 % of people with schizophrenia smoke cigarettes, despite the fact thatsmoking typically uses up almost all of their very limited disposable income and has all of
the known health risks. There are now suggestions that schizophrenia is associated withabnormalities in neurotransmitter systems that are related to nicotine. Smoking may help tostimulate brain areas that are under-active as a result of the illness itself.

The fixations on cigarettes could get pretty extreme. Many patients scoured the ashtrays
for butts that still had tobacco in them. These would be relit if they were big enough.
The smaller ones were collected and rolled up into pieces of paper from magazines. One
young man had dispensed with the whole business of lighting the cigarettes. He simply
ate them. One day he was being escorted to another building on The Campus. His
propensity for picking up cigarette butts and eating them was well known so staff had
restrained his hands behind his back prior to the walk. Even that strategy failed when
he saw a butt resting on top of a snow bank. Before the startled staff member could
react the man dove into the snow head first, neatly grabbing the smoke in his mouth
before he sank into the snow. He had eaten the butt before he was pulled out.
Vladimir had been on The Unit for seventeen years. He had assaulted a policeman
because of some paranoid ideas involving his wife. The charts indicated that Vladimir
spoke only Ukranian. No one had been able to talk with him in the entire time he'd beenon The Unit. My own attempts to speak with him were always unsuccessful. I didn't
know if he was actively crazy or had a dementing illness. Since he rarely got out of bed
and never interacted with anyone it was impossible to tell what his internal world was
like.
Finding a person who could speak Ukranian was the obvious solution, but this had
never been seriously attempted. One of the social workers was given the task of findinga translator. After a couple of months the big day arrived. A Russian Orthodox priest
came to The Unit, wearing robes and all. We went down to Vladimir's room to ask him
some questions. When the Priest asked his first question- in Ukranian- we werestunned when Vladimir answered him in English.
Erika was an older woman with a thick Austrian accent. She sounded much more likethe typical caricature of a psychiatrist than I did. She'd been committed after assaulting
her husband with a duck. She had a longstanding "erotomanic fixation" on her
outpatient psychiatrist and had become furious when her husband refused to drive her
to the psychiatrist's home so that she could deliver a love letter to him. The problem wasthat she'd gotten the duck from her freezer so it was a potentially dangerous weapon in
the eyes of the court. Like many women with Bipolar Illness you could sort of judge
how manic she was by her jewelry. When Erika was wearing two or more rings on eachfinger you knew she was going to be difficult to deal with. Her other clinical indicator
was whether she was wearing shoes. Years earlier Erika had made a suicide attemptduring one of her depressive episodes. She had laid across the railroad tracks near herhome but as the train approached she had a sudden change of heart. She almost got
out of the train's way except that it neatly severed the big toe on her right foot.
Amazingly, she incurred no other injuries in the incident. In the years that I knew her,when she was shoeless and showing the missing toe that was another sure sign oftrouble.

Laura was another of the Bipolar patients that would come to us as a result of hermania. When her mania had reached a sufficient level she often concluded that she waspregnant. For some odd reason manic women often conclude that they have many
fetuses in them. Some claim to be carrying ten or more babies at once. This happened
often enough that I began to call it "the litter delusion". During this hospitalization she
had decided to take some contraceptive measures to keep yet another litter fromdeveloping. She was wearing a moist bath towel wrapped around her head when I cameto see her. She explained to me that she had a large hole in the top of her head. The
towel covered it up but had to be kept moist "for protection". When I asked what sheneeded to be protected from she whispered "air born sperm".
One young male manic was severely "hypersexual". His efforts to copulate with every
female on the ward - staff and patients alike- had finally resulted in his being put in a
seclusion room. There was a small window, maybe five inches square and at eye level,that allowed staff to observe the patient that was in seclusion. For several days thatyoung guy tried to expose himself to every woman that walked by. "Hey, Hey" he'd yell,trying to get ladies to look at him. He jumped up and down like he was on a pogo stickas he tried to get his penis in front of that little window but it was just too high off theground for him.
Shortly before I left The Unit we joined the computer age. An old desktop that had
become too obsolete to be used somewhere else in the State bureaucracy was delivered to
my office. Of course the patients had a variety of reactions to the newmachine. "There are heads in there with squashed down brains in them- I used tomake those things" one elderly man claimed.
Gigi was another patient who had managed to stay on The Unit- over her bitter
protests- for many years. Part of the strategy in staying in a State Hospital for years on
end involved convincing staff that you hated it there and wanted desperately to leave,then acting in a way that made it clear that discharge was impossible. Gigi had not left
the unit for even a brief walk in years, even on the occasions of rare visits from family.
Gigi was in her seventies when I met her and had had a unique delusional system forseveral decades. No treatment had ever shaken her core beliefs. She was totallyconvinced that all humans had “39 brain cells” and that a single one of hers had“turned irrational”. As she once put it, “I have had that sick cell in my body since I wasseven months in utero…it directs me and talks to me…That’s why I must rock back andforth…I have heard it speak at times- it has a very weird voice”. Unfortunately Gigi’s“sick cell” had told her to kill herself on occasion and we knew of at least two serious
suicide attempts. Once she had taken a potentially lethal overdose of medications.
Another time she had driven her car off a bridge.
Like many people with schizophrenia, Gigi evidenced no concern whatsoever forpersonal hygiene. Oftentimes it isn’t like they make a conscious decision to neglect theirself-care. Its more like the matter doesn’t even come up on a neurological level. Their
brain may not attach any importance to the way that they actually look or how others
might view them. Gigi’s hair was matted down and she wore the same tatteredhousedress every day except when the nurses insisted that she finally had to surrenderit for laundering. She had a few teeth left but they were dark and twisted. She had comefrom a wealthy family and was convinced that she was a genius.
It is always a temptation for even trained mental health professionals to try to rationallypersuade psychotic people that their delusional beliefs are false. I fell into the trap early,
showing her atlases of neuroanatomy, quoting her estimates of how many billion nerve
cells were actually in the human brain, and so on. Of course this did no goodwhatsoever. 39 brain cells is what humans were born with and any competent physician
should know that. By definition, a person with delusions believes that their beliefs aretrue. They can quite literally decide that the person who doesn’t agree with them is crazywhen their beliefs are challenged. Plus, by the time they come to psychiatric attention
patients like Gigi have usually had all sorts of well meaning people try to point out theerrors in their thinking. So I should have known better. Gigi quickly became convincedthat I was both ignorant and “an alcoholic”. She became resistant to meeting with me
and was often quite hostile and demeaning.
Eventually Gigi consented to brief meetings with me again when I suggested that I’d be
an even worse psychiatrist for her if she wasn’t giving me input into her treatment. I
decided to focus on getting her to tell me her life story rather than eliminating her“symptoms” and she did enjoy talking about her past. At times we’d laugh at my foibles
or those of the nursing staff- there was plenty of material to chuckle about. This wasback in the days before Clozaril had been introduced so there weren’t a lot of good
medication options when patients didn’t respond to the usual drugs. In Gigi’s case it
turned out that she had had a good response to lithium many years before. So we tried
adding a low dose of lithium to her antipsychotic medication. As occasionally happens,
the lithium seemed to “augment” or turn on the action of her antipsychotic medicine ina dramatic way. Long standing delusions rarely disappear quickly or entirely. Instead
they seem to lose their emotional emphasis in the person’s inner world. This was thecase with Gigi. She never believed that she had been wrong about that 39th brain cellthat had gone rogue on her. But the cell gradually became less bothersome and she wasable to think about other things at times.
As Gigi’s condition improved we had to face the inevitable prospect of her discharge.
Fortunately there was a nurse who had known her throughout her long hospital stayand had somehow managed to form a decent relationship with her. That nurse was
finally able to persuade Gigi to go for walks to the hospital store to buy cigarettes andcoffee. Then the big day came where Gigi agreed to go to downtown Minneapolis with

her nurse “to see how the city has changed”. Her reaction to the trip was striking. We
tend to focus so much on the aberrations in meaning that people with psychosis attach
to things around them that it is easy to forget how strange things can be for them at themore basic levels of perception. When she related how the city had changed since shelast visited she was quite focused on a new skyscraper that had been constructed. “ Youwouldn’t believe it”, she said, holding her thumb and forefinger about an inch apart.
“Those morons built a beautiful building but the windows on the upper floors are only
this big!” Later she referred to the “miniature helicopter” that she had seen flying overthe city. Despite everything that I thought that I knew about schizophrenia I was
stunned to learn how different that the picture of the world presented to her by her
nervous system really was. The fact that objects look smaller at a distance was no longer
a part of her perceptual universe.
Emily lived alone and missed her children terribly, although she missed them in her
own unique way. Rather than feeling the pain of longing for her grown up kids ( whowanted nothing to do with her in reality ) Emily decided that her children visited her
regularly. It's just that they assumed the form of squirrels when they came to see her.
She would leave nuts out to entertain the kids when they visited. On holidays andspecial occasions she'd put out a little bowl of Jack Daniels. Her social worker asked
that I come meet with her in an attempt to persuade her to take the antipsychotic
medication that she apparently needed. I was pretty pleased with myself after our
meeting, as she did consent to taking some medicine and was already becoming lessdisorganized. Within a few weeks, however, she decided to stop the medicine again and,surprisingly, was claiming that it was me who had instructed her to do so. It turned outthat I had been "speaking to her through her grapefruit juice" every morning since
we'd met and was now finally giving her the sort of advice that made more sense to her,i.e. "don't take any more of that medicine - it's poison".
Hannah was trying her best to maintain a dignified front in commitment court. All of asudden, in the middle of her attorney's attempt to plead for her release, Hannah let own
a loud scream and fell writhing on the floor. The court deputies and I rushed to her
assistance, fearing that she'd had a heart attack. "Cosmic rays" she gasped. "The rays
got me". Her attorney's case did not go well after that.
After we'd talked for a while Alma indicated that it was now safe for her to leave myoffice. " I'm pretty sure that my feet will keep me on the ground now", she said withobvious relief. "They are a lot heavier now". I was pleased to learn that I could havethat sort of effect on a person's relationship with gravity.
Our clientele on The Unit was by no means limited to severely psychotic people withschizophrenia. All sorts of brain problems could get a person admitted to The Unit. The key
factor was whether they were too confused, vulnerable, or unpredictable to be cared for in
the other wards of the hospital.

Tommy was a man who had suffered a brain injury in a motorcycle accident. He was
the exception to the general rule that brain trauma magnifies or worsens preexisting
personality traits. Before his injury Tommy had been quite nasty and ill-tempered but
now he was relatively pleasant and docile. In fact the few family members that visitedfound that they liked the brain damaged version a lot better than the old Tommy.
Unfortunately, his new found tranquility was accompanied by a profound memory
deficit and almost total absence of problem solving abilities. One day I saw him walktowards a drinking fountain on the way to the smoking room, carrying a cigarette andlighter. I turned to my medical student and predicted “ He’ll never be able to handle
this- it'll be too complex for him". Sure enough, Tommy stopped before the fountainand looked at it with puzzlement. He finally figured out that he needed to push the
button to get the water to come out but when it did he placed his cigarette under the
stream rather than taking a drink. "Aw fuck" he yelled, throwing the soggy cigarette to
the floor. The student looked at me in amazement and asked “ how did you know he’ddo that?” Of course I didn’t know that he’d put his smoke under water. I just new thatthe complicated process of taking a drink while carrying a cigarette would be beyond his
capacities.
Robert was an elderly man who had been an alcoholic for many years prior to fallingand hitting his head on some concrete steps. The resulting brain injury changed his
personality, leaving him very suspicious and irritable. Despite the seemingly clear
relationship between his suspiciousness and the head trauma, he had been on The Unit
for several years with the diagnosis of “paranoid schizophrenia” and was treated with
antipsychotic medicines. Robert had the peculiar habit of writing down just about
everything that he saw or thought about in little notebooks. He’d follow me around theward, pushing his notebook at me, insisting that I read what he’d written down- which
was all basically nonsense. It turned out that what Robert actually suffered from was“temporal lobe epilepsy”, a peculiar seizure disorder that had resulted from the head
injury. One of the odd symptoms of his disorder , in addition to the personality change,
was “polygraphia”. Polygraphia means essentially “too much writing”. Once we got
Robert off his antipsychotic medicines, which were making his seizures worse, and on
to a medicine to tame the seizures he improved significantly. His drive to write down
every little injustice faded away and his mood improved. He left us to live with adaughter in a distant state.
Leona had suffered brain damage as a result of strokes and had one of the worst
memories on record. I could talk with her for a while, leave the room for thirty seconds,
and when I returned she could not recall having ever met me before. One day she had avisit from family and when they left she became quite agitated, screaming loudly thatsomeone had stolen her wallet. She did not actually have a wallet with her but her brain
was somehow aware that something important had been there previously and had beentaken away from her. Reassuring her that it was her family- not her wallet - that had

departed did little good. She did not remember that her family had been there justminutes before. Of course she forgot about “the wallet” in a few moments too soeverything was quickly back to normal for her.
Martin had the same sort of brain injury that Leona had but his presentation was
different. “Multi-infarct dementia” results from a series of strokes and the location of
the strokes largely determines what the resulting symptoms will be. Martin was a Native
American man who had a history of alcoholism and uncontrolled hypertension. The
strokes had left him with a severe memory loss, an aphasia (an inability to speak) andtremendous difficulty controlling his basic impulses.
Sometimes life imitates art in funny ways. I knew Martin for several years and, likeeveryone else on the staff, was convinced that he was completely mute. I had managed tolocate a sign board that is used with deaf people and he’d communicate by pointing at
symbols on the board or by writing me simple notes. One night I came to The Unit in
the wee hours of the morning and was shocked to see Martin talking on the telephone.
Of course the character of “Chief” in One Flew Over The Cuckoo’s Nest came to mind
immediately. He smiled sheepishly when he knew I’d found him out. The movie analogy
didn’t hold exactly though. Martin’s speech was very clumsy and difficult to understandand it was clear that some genuine aphasia was indeed present.
It wasn’t his speech problems or even his memory deficit that had left Martin locked up
for so long. It was his problems with impulse control - especially sexual impulses.
Martin would try to have sex with just about anyone who was willing or had just beenleft unattended for a few moments. Gender was of no consequence. It was just a part ofeveryday life on The Unit to walk down the hall and see Martin with a big grin on his
face and his organ out for everyone to see. He’d sidle up to unwary patients, staff
members , and visitors , trying to rub himself on them for a little while before being
driven off by the predictable screaming.
Martin was pretty clever for a demented person. He had somehow learned how to pickthe locks to The Unit with an old credit card and was always trying to escape. One time
he made it as far as the parking lot and managed to get a worker's truck started. Hemight have gotten away except for the fact that a can of motor oil in the truck captured
his attention. Martin had drank over half of the quart of Quaker State before staff
members caught him and returned him to The Unit.
Martin was another person whose behavioral problems were clearly going to makedischarge impossible unless something drastic was done. I began to look into thepossibility to reducing his excessive sexual drive with “antiandrogens”. There was asmall literature on using Depo-Provera (a female hormone often used for birth control)
injections to accomplish this. We discussed this with Martin (to the extent possible), hiswife, and the hospital ethics committee. The entire medical staff reviewed the issue.

Martin and his wife consented to have him start the injections. Baseline measurementsof the testosterone in his bloodstream were taken and we finally began to inject him with
Depo-Provera each week. As his testosterone levels came down so did his sexual drive.
He stopped exposing himself and no longer tried to mount everyone. He gained a little
weight but otherwise seemed to tolerate the injections quite well. Within a relatively shorttime it became possible to discharge him to a nursing home much closer to his wife andfamily.
While there are all sorts of legal and ethical issues around a treatment like Depo-Provera
injections, which essentially represents "chemical castration", this seemed to represent the
only way that Martin would ever be able to return to a non - hospital setting. We madeevery effort to obtain truly informed consent from he and his wife and had a lot of opinions
on the table before proceeding with this. One wonders why this type of treatment is notroutinely offered as a voluntary option to incarcerated sexual offenders who clearly cannot
control their sexual impulses and have no other prospect of ever returning to live safely insociety.
The Unit used to get patients with Alzheimer's Disease but something else usually had
to be going on with them for them to come to us. They had to have other problems, e.g.
paranoia, medical problems, hitting, or other behavior issues that no longer made living
in regular nursing homes possible. In Dan's case it was that he was just too confused
to get by anywhere else. When he came to The Unit he was wearing two pairs of
trousers- with his underwear on the outside of them. One time I saw him walking down
the hall with a tattered garbage bag pulled over one leg. He was very serious as hestruggled to keep the bag pulled up with both hands as he walked. Later he was seen in
the smoking room wearing four baseball caps on his head. I was surprised one
morning to see him pushing his entire bed down the crowded hallway. If there was anunderlying reason for these odd behaviors I never could figure out what it was.
Perhaps these things made sense only in the reality that Dan was now living in.
The Alzheimer's patients were hard for us to deal with. They tended to die within at least
five years of the onset of their illness and most of them were already in the advanced stagesof it by the time they came to us. Sometimes tiny doses of antipsychotic medications madethem more comfortable and manageable but otherwise we didn't have a lot to offer them. By
definition, they had terrible short -term memories so any sort of attempts at talk therapy
would be quickly forgotten. Most of them did maintain some memories of their moredistant past though. I always tried to impress upon the medical students - that were aconstant part of life back then- that just taking the time to listen to the stories of their past
was sometimes the kindest thing that we could do for these demented people.
Mary had been hit by a car years earlier and had never recovered her ability to makenew memories. One of the things that she could never remember was that she wasn’t
actually pregnant. Her belief that she was pregnant was so powerful and complete that

her body actually looked exactly like she was about 26 weeks pregnant. Her presentation
was so convincing that she’d had a number of expensive obstetrical work - ups when
she went to Emergency Rooms complaining that “something’s not right with the baby”.
Mary was another patient that frightened us by running away. She’d given her social
worker the slip when they stopped for gas on the way to an interview at a nursing home.
She hitched a ride and eventually ended up somewhere in rural Tennessee. When she
was finally found by their police and transported back to The Unit I was surprised tolearn that she had acquired a pronounced Southern drawl. Apparently she couldn’t
remember that she did not usually speak with a southern accent. Her old way of
speaking slowly returned over the next couple of months that she was on The Unit.
About a year after her discharge Mary was returned to The Unit on another mental
illness commitment. Since she arrived without cigarettes we went for a walk to thehospital canteen to buy some. I was surprised that she remembered me. As we caught
up I asked her “do you have any memories of that time you took off to Tennessee andcame back with that southern accent?” She didn’t recall much of the trip. The amazing
thing was, though, that as soon as I reminded her of that accent it returned in fullforce. This time it didn’t stick around as long- only a couple weeks. But I never could
figure out how that accent had come back. I was convinced that there was nothing
volitional about it on her part.

Few conditions are harder for a hospital ward to deal with than "screamers". These were
patients that yelled incessantly. The Unit had two of them and they were both world class atwhat they did.
Andrew was a man in his twenties who had had no psychiatric problems at all until hesuffered brain damage in an automobile accident. He was in a coma for nearly twomonths and when he woke up he woke up screaming. He basically yelled every momentthat he was awake. "Help me", "I'm hungry" and "my butt hurts" constantly
resounded through the halls of The Unit. He often couldn't remember that he had eaten
just a few moments before. Andrew could walk with the assistance of two people so we
tried to get him up and about to maintain whatever strength and coordination were left
in his legs. Since I was one of the few male staff members on The Unit I'd often help
out with trying to get him walking. Andrew taught me a great lesson about never letting
your guard down with a brain-damaged person. They are often so confused andimpulsive that you can't predict how they'll respond to a situation.
One day as we were trying to get him walking he suddenly grabbed my testicles in, what
seemed to me, to be a death grip. It took two of us to get his hand unclawed. This may
have been the longest minute of my entire life. Another time he suddenly struck out as I
was standing behind him, catching me square in the mouth with his fist. On neither
occasion had he even seemed angry beforehand. Andrew also had the habit of reachingback into his soiled "Depends" and throwing feces at people who entered his room. He
did not seem to be have any animosity to any of us as individuals. He just seemed so
terribly-and understandably- upset about what had happened to him that his anger
would come out when we would not expect it.
Ironically, Andrew was responsible for getting the patient who had proven the hardest
to discharge to finally leave The Unit. Maureen was a very frail woman in her earlyeighties. She had lived on The Unit for some 48 years. Records indicated that she had
become convinced that a neighbor was responsible when Maureen's mother had died ofnatural causes. Maureen had calmly walked next door and killed the man with a pistol
following her mother's funeral. The Unit had been her home for a long time and shewould have absolutely nothing to do with me since I was someone who clearly had theagenda of discharging her. To compound matters, Maureen had a "Conservator of
Person" who had the legal right to approve or disapprove any proposed community
placements. The Conservator would not approve any place unless Maureen wanted togo there. And Maureen let us know that she wasn't going anywhere.
When we'd had Andrew on The Unit for a while it suddenly occurred to me that hecould help us. I arranged for Maureen to be transferred to the room directly across thehall from Andrew's. After a couple weeks of hearing "my butt hurts" for hours on end
the idea of living in the State Nursing Home began to look more attractive to Maureen.
We always made a point of mentioning how "quiet and peaceful" the place was. Her
conservator approved the transfer and, after 48 years, Maureen left us to live in aquieter place. The story ended sadly, however. Maureen had insisted for years that she
would certainly die if she lived anywhere else besides our weird, chaotic Unit. We
received word a couple months after she left that she had, indeed, passed away.
Sometimes your beliefs can kill you.
Martha was our other screamer and in many ways she was more difficult to deal withthan Andrew. One of the biggest problems was that her room was two doors down frommy office. She had had a series of strokes that left her blind, unable to walk, withmemory impairments, and in constant physical and emotional pain. In contrast to
Andrew, she could carry on a rational and polite conversation. What she absolutely
could not tolerate was being left alone, even for a moment. As soon as a staff member
left her room the screaming would begin. This was a shrill, high pitched "help me" thatcarried an amazing distance. On a summer day with the windows open I could easily
hear her in buildings on the other side of the campus- a good 300 hundred yards away.
This was another situation where the patient's symptoms were quickly equated with thepsychiatrist's skills. Only now the entire hospital seemed to be cursing me under theirbreath every time that nerve wrenching "help me" started up again. We tried everything
we could think of to quiet Martha down. I even arranged to have her room lined withacoustical tiles in an attempt to soundproof it. Nothing worked. She had already been

tried on just about every class of medications that one could think of and nothing had
put a dent in her screaming. Major tranquilizers, minor tranquilizers, antidepressants,
lithium, antiseizure drugs, even some of the blood pressure medications thatoccasionally calmed people down were of no apparent benefit. The only option left- andone that was heavily favored by staff throughout the hospital- was to keep her so heavily
sedated that she would not have sufficient energy to speak, much less scream. But there
were some touchy ethical and quality of life issues that made that option hard for me to
exercise.
Two basic things seemed to turn things around for Martha. One involved talking to hervery candidly about how her various negative and demanding behaviors- which were by
no means limited to the screaming- made it hard for people to be around her. We
arranged for contact with staff to be limited if she was yelling. As she tried to be a little
easier to deal with we tried to get the staff to seek her out and spend more time with herwhen she was "being good". Pretty basic behaviorism-reward the good behaviors, try toignore the bad ones. The other involved opiates - perhaps the one class of medications
that had not been tried with her. The idea was that maybe the multiple strokes had also
damaged the pleasure systems in her brain, resulting in her seemingly constant agony.
This was another case for the hospital Ethics Committee ( which I chaired in thosedays ) to review. Since the other members of the committee had also had to deal with
Martha's screaming, albeit from a greater distance, and given the fact that nothing else
had worked for her, the request to use opiates in her care was quickly approved.
Martha, herself, was all for the idea. Opiate addiction seemed like small potatoes
compared to what she was already forced to deal with.
We were surprised when Martha didn't really take to the painkillers as we'd anticipated.
She used them only rarely but seemed to appreciate knowing that they were available if
she was having a particularly rough day. The Unit became a much more pleasant placefor everyone as Martha became more quiet and comfortable. When the time came totransfer her to a community nursing home we sent our Behavioral Analyst andMartha's primary nurse along to help teach their staff how to best deal with her. This
was a discharge that we did not want to go sour. The prospect of having her returned to
us in a decompensated and screaming condition was more than any of us could bear.
Bart was a man that did take to painkillers in a big way. He had an advanced case of
Huntington's Chorea, a dreadful genetic illness that robbed him of his muscle control
and turned his body into a never - ending series of involuntary spasms. The
Huntington's was slowly taking away his mind as well. Bart was one of the many people
that had been sent to Minnesota from a neighboring state because of the fact that ourmental health system, dreadful as it was, was so much better than that available backhome. He'd had problems with a back injury years before and had developed a fondness
for Percodan- an opiate based painkiller. As he was clearly dying it seemed that
addiction to opiates should not be a concern. We let him titrate a different opiate(Percodan's dosing was limited by the amount of aspirin in it ) to a level where he felt
relaxed and comfortable. Bart was quite appreciative. Yet every time we tried todischarge him to a nursing home a new psychiatrist in the community would take away
the painkillers. Bart would become pretty upset about that and act up so that he'd be
returned to us in short order. He knew that he'd have his painkillers resumed. We
could never understand the problem with giving a dying man with an incapacitating
disease the pills that made him feel better.
Psychiatrists have no problem with the idea of removing symptoms but when it comes touse our medicines to provide some degree of pleasure to people - even those whose brains
are damaged in ways that keep them from experiencing good feelings - we show a wide
range of opinions.
We had a number of Huntington's Chorea patients on The Unit over the years but
none of them rivaled Mabel's story. Mabel had been on The Unit for over thirty years
with the diagnosis of Huntington's. The nursing staff was terrified of her because ofher history of violence. Mabel had had all of her teeth removed after biting off the
tongue of a man who had been foolish enough to French kiss her. She'd also had two
frontal lobotomies to control her aggression. When I met her she lived her waking
hours in a "Geri chair"- sort of a wheeled lounge chair that you could be locked into.
She was in that wheeled chair so much that I once suggested that in her next life shewould come back as a golf cart. Mabel had the most pronounced movement disorder I'dever seen. Her body was in constant motion, with snakelike movements of her limbs andcontinual facial grimaces. As I sat with Mabel and came to know her it became
apparent that there were two parts of her clinical picture that did not make sense. She
did not show the progressive dementia that Huntington's patients inevitably experienceas their brain essentially rots from the inside out. Mabel still followed the soap operas
and could remember the story lines in detail. When I looked into her family history, she
did indeed have Huntington's disease throughout her mother's side of the family. But
her mother herself was in her eighties and did not have the illness. So she couldn't havepassed it on to Mabel. It turns out that what Mabel had was perhaps the world's worst
case of tardive dyskinesia. Her nonstop involuntary movements were not a result of an
illness, but of the medication (Haldol again) that had been given to her in an attempt tokeep her calm and manageable. She had been treated on The Unit for over thirty years
for an illness that she didn't have.
Lewis was a young man who had gotten into a fight and had been severely beaten witha baseball bat . He was so confused when I met him that I decided to give him my"cigarette test". He was given a cigarette and lighter to see what he could do. Any longterm smoker has their cigarette habits pretty much ingrained after a while. I knew that
we were in for a rough ride when he looked at the cigarette with puzzlement, then put
the lighter in his mouth sideways.

Lewis' s purposeless and unpredictable assaults on staff members, myself included,
were so severe that he had to be kept in a locked seclusion room. One day, after several
particularly trying months, I was observing him through the small window of the
seclusion room door. I was strangely delighted by what I witnessed that day. Lewis had
defecated in the corner of the room, as he often did. But on this occasion he picked up
the turd and carefully placed it on a radiator. At that moment I knew that we had turned
the corner in his treatment. That one little purposeful behavior, that attempt to make hisenvironment better, was something that we could not have imagined for him previously.
The prediction did prove to be accurate. Over the ensuing weeks he began to show moreawareness of himself and was able to walk on The Unit with a couple staff membersthat found a way to get along with him. The assaults faded away. Several years later welearned that he was living in a supported apartment.
The brain's plasticity, even in the face of severe damage, can be a wondrous thing tobehold. Recovery from brain injuries can go on for at least two years after the damage isincurred. So you never can tell exactly what deficits someone will eventually be left with.
But sometimes we have to look extra carefully to find those glimmers of improvement thatcan make the work with these patients seem worthwhile. If someone had told me during myresidency that I'd be thrilled because a man picked up his own feces I would have neverbelieved it.
Brad was a deeply schizophrenic man who was catatonic when he came to us, barely
moving or responding to his environment at all. But we were surprised to learn thateven in the midst of his catatonia Brad was still a collector. The problem was that hewas collecting his own feces. A nurse had noticed a strange odor emanating from
Brad's dresser and was surprised to learn that he had carefully packed each of hisbowel movements into plastic bags, bags that were apparently too valuable to discard.
Susie was another collector but her specialty was used tampons. The nurses werealways finding them stuffed into her dresser. One day I was trying to talk with her
about why she would save things of this nature. She became very indignant with me.
"They turn into babies if you just let them be", she cried. "What kind of Doctor doesn't
know that?"
Chuck suffered from both mental retardation and schizophrenia. He had lived in thecommunity his entire life, with the assistance of a brother. Once the brother died,
Chuck could not manage on his own but it took a while for him to come to the attentionof authorities. When neighbors' complaints finally brought in the Housing Inspector
the condition of Chuck's home was truly appalling. The basement was flooded withwater. An enormous hole ran through the kitchen floor so that you could see throughto the flooded basement below. But it was the cats that really made the place
uninhabitable. Dozens of cats that were barely alive and many dead cats were scatteredthroughout the house. Cat feces were everywhere. His freezer was filled to the brim withthe remains of other cats. Chuck was convinced that modern science would soon beable to bring the dead cats back to life so he would never dispose of their bodies.
As far- fetched as Chuck's delusional system was, is it really more bizarre than the story of
Ted Williams' remains?
Lucy was another favorite. She was the patient who "died" nearly every night, only tobe reborn as "an atom bomb", "John F. Kennedy", “The Blessed Virgin Mary” orSatan. She was still a relatively young woman but did not have a single tooth left in her
mouth. This left her with an odd appearance and limited her diet so I decided that wewould take whatever steps necessary to get Lucy some dentures. It took a lot of work to
prepare her- and the dentist- for the ordeal involved with examinations and fittings but
after some months the big day arrived. When Lucy put in her new dentures she looked
like a different woman- at least ten years younger and dramatically more attractive. The
staff and myself were thrilled by what we had accomplished for her. Lucy, however, wasless impressed. Within a week the dentures had gone through the laundry in the pocketof her jeans. Soon afterwards we were surprised to see that an elderly woman on The
Unit suddenly had teeth, when she had had none before. Lucy had traded her dentures
for a pack of Marlboros.
More than money, cigarettes were the unit of trade on The Unit. Just about anything
could be purchased if you had enough smokes. One day we were saddened to learn that
one of our women had prostituted herself to a male patient for one cigarette. To makethe story even more tragic, when the act was completed he refused to pay her, sayingthat "she wasn't worth it".
Ginger was a large, powerfully built woman who split her time between Minneapolis
and St. Louis. When things got rough for her in either city she would always manage to
get herself admitted to psychiatric hospitals, where she knew that she would be cared forand she wouldn't need money. In fact sometimes she got herself admitted to the State
Hospital to make money. She would quickly show that she was on her best behavior sothat she'd earn passes into town. Once she had the freedom, her coffee smuggling
business kicked in. She'd make over a hundred dollars per month selling coffee back inthe days when it was banned on The Campus. Patients would make slurries of instantcoffee and water from the drinking fountains. A few bypassed the adding water stepand simply ate their coffee. The staffs efforts to keep coffee away from the patients were
never successful, nor could they be.
Ginger had two preferred ways of getting into psychiatric hospitals. One wasswallowing foreign objects. She'd swallow anything from marbles to razor blades. One
time after she'd swallowed a number of coins she had to laugh when I said "remind me
not to ask YOU for change for a dollar".

Once she'd swallowed several large paper clips that would have to be surgicallyremoved. The young surgical intern patiently explained the endoscopy procedure that
Ginger would have to undergo, then offered her his clipboard and pen so that she
could sign the necessary consent form. To his horror, she quickly swallowed his pen.
Ginger's other ticket to admission involved cutting her throat. She had done this somany times that there were multiple rings of scar tissue visible at the base of her neck.
She had always managed to cut herself severely enough to need stitches- and to shed an
impressive amount of blood- but had yet to nick a major blood vessel. It seemed to bejust a matter of time before she'd kill herself by accident.
As it became obvious that Ginger was in no way ready to give up these long standing
behaviors our attention shifted to finding a way to get her what she wanted - psychiatrichospitalization - without having to go to such dangerous extremes to get it. We looked atvarious options before settling on the "Benadryl Overdose Strategy". In this maneuverwhen she wanted to get into the hospital she would take a few Benadryl capsules, wait
until she was getting pretty sedated, then go to the emergency room saying that she'dtaken an entire bottle of Benadryl. Blood tests would, of course, be positive for the drug.
She would be viewed as a person with suicidal intent and a lethal plan, without having
to truly endanger her safety as she had so often with her other ploys. I had some ethicalissues around this early "harm reduction approach" but ultimately came to believe that
it was the best that I had to offer Ginger. There was an unanticipated benefit of thisapproach. She was sufficiently touched by the fact that I'd go to this length to try to help
her, without insisting that she change her way of operating, that we developed a close
relationship.
"Harm Reduction" is a popular concept in the Chemical Dependency Treatment field thesedays. The idea is that maybe everyone is not able to make the jump to total abstinence fromdrugs and alcohol, so just getting them to cut back, or to reduce the harmful consequencesof their addictions, can be a worthwhile goal. Of course this makes perfect sense in somecases. And who says that our goals for people, be they "total sobriety" or whatever, shouldbe the goals that they will truly hold for themselves? Many of us who work with severely
mentally ill people had been familiar with a "Harm Reduction Approach" before the concept
ever had a name. There was often nothing else that we could offer.
When someone can see you for who you truly are and can still tolerate you, warts and allor better yet can actually like you- it has subtle effects on the way you think about yourself.
This is one of the major, but often unrecognized, benefits of all psychotherapies.
Stanley became quite agitated one day as I walked by. He began to rant and rave about"all those bastards in business suits". I explained to him that I was wearing a suit thatday (a very rare occurrence on The Unit ) because I had to go to court and didn't want
the judge to think that I was disrespectful. Stanley's demeanor quickly shifted and, out

of the blue, he asked " Who's the Champion anyway, The Crusher or Nick
Bockwinkle?". I explained that to the best of my knowledge both of these gentleman had
retired from wrestling well over a decade ago. Stanley shook his head and replied "Theymust be wrestling in Milwaukee".
When I asked Stanley to come to my office he relied that it was too far to walk. "I need awheelchair" he said. " Electric. Battery operated. Twelve volt. Dry cell". When we got tothe office he asked where my secretary was that day. This puzzled me, as I did not havea secretary, until I realized that he was referring to my medical student Trish. I
explained that Trish was on vacation, touring Greece and Italy. Stanley replied that
there was "nothing left to see in Germany or Italy". He then demanded that I "give him
a form". I was at a loss to understand what he really wanted. I brought out some of thevarious forms that I had to complete as part of Unit business but they didn't interest
him. What he had wanted was the manila folder that I kept some of the forms in. I
found a blank folder and handed it to him. At that point he got up and left my officewithout a word.
Psychiatrists use the term "Thought Disorder" pretty loosely these days. Technically there
are two main types of thought disorders: Thought Content and Thought Form Disorders.
Thought content obviously refers to the things that people think about, the content of theirbeliefs. Thought form refers to the thinking process itself. Many psychotic people
demonstrate what is called "loosening of associations" or "derailment" of their thinking.
They embark on a train of thought but each thought fragment calls up other associations sothey skip from topic to topic in ways that may only be understandable to them. Stanley wasa master of another type of thought form disorder called tangentiality. Entirely new topics
could spring up without any seeming relationship to what was going on just a moment
before. An attempt to engage him around any particular topic or question was usually met
with a totally unrelated response.
I was always looking for ways to find some common ground with these unusual people.
In Stanley's case we finally settled on cards. He said that he liked to play but it turned
out that the only game that he knew was "War". He wouldn't consider learning anyother games, no matter how simple. So I'd hear this faint knock on my door and it
would be Stanley, looking to play cards. War is, of course, the most basic of children's
card games. You each turn up your cards and the high card wins. Stanley tried to cheaton many occasions but I'd never let him get away with it. It didn't matter anyway. In
over two years of playing war with Stanley we never came close to finishing a single
game. Right in the middle of the game he'd just get up and leave the office. It didn't
make any difference if he was winning or losing.
Malcomb was a man who made Stanley look accessible by comparison. Young, strong,and quite autistic, he seemed to live entirely in his own world. He almost never spoke
except to mumble "Popeye". Being a cartoon fan myself, I tried to engage him inconversations about Popeye, Miss Olive Oyl, Brutus and other characters from theshow. When that failed I tried talking with him about Underdog, The Flintstones, Yogi
Bear- essentially any cartoon that I knew about, I'd talk about. I had learned thatsometimes I could wear mute people down. If they wouldn't talk I would, babbling one
inanity after another until they couldn't take it anymore and had to either correct me ortell me to shut up. Nothing reached Malcomb though. Then one night he managed toget one of the nurses alone in the hallway. After wrestling her to the floor he had tried
to get his fingers into her eye sockets to remove her eyes. Fortunately another patient
heard her screams and was able to pull Malcomb off even before the other staff
members arrived- and before any permanent damage was done. "Popeye" had meant
something entirely different to Malcomb than had ever occurred to me.
At our most basic levels of perception our brains often have to choose between "same" or"different". Its a decision that we take completely for granted until we see that people canguess wrong on the issue. All sorts of strange things can happen when they do. Sometimes
even standing up or shifting position in one's chair can lead a psychotic person to conclude
that you are now a different person. If one thing changes, everything can change. Similarly,
if two people or things have a single attribute in common the brain can decide that they are
identical.
Steve was my very first patient with "Capgras Syndrome". This is a belief that people
familiar to you have been replaced by identical imposters. In Steve's case it was his
parents. He'd lived with his parents all of his life but was now convinced that that his"real parents" had been abducted to California. The beings that he shared the housewith were, he was certain, "computer generated images". As psychotic as he was, Stevewas way out of my league when it came to playing chess. I could never come close togiving him a good match so he basically just toyed with me. I was the guy with the
medications and authority, though, so he rarely dispatched me as quickly as he could
have. After several months of taking antipsychotics Steve returned to his family home to
live. He was still convinced that he was living with computer -generated images but hedecided that they were actually pretty decent "images" to live with after all.
Alice had a similar syndrome. De Fregoli's Syndrome this one was called. As we talked
in our initial interview it soon became apparent that, as often happened, Alice thoughtthat she had known me before. Slowly it dawned on me that it wasn't really me that she
thought that she knew. She believed that I was actually a nurse ( a female at that ) froma hospital that she had stayed at previously. She thought that this nurse was able tophysically transform herself into other shapes. This time she believed that the nurse wasassuming the guise of a psychiatrist. I knew Alice for over a year but she never seemed
convinced that I was the person that I claimed to be.
Rebecca may have taught me more about mental illness than any other single person.
She was my "psychotherapy patient" at Cornell. She had been tried on all of the usualclasses of medications and had underwent a trial of shock treatment but nothing had
worked. Severely catatonic, she lived almost entirely in her inner world. She didn't speak
for the first month that I knew her. Didn't toilet herself. Didn't walk. About the only
time she'd move was too dig her fingernails into her face, leaving deep scratches. The
nurses used to wheel Rebecca into my office in a wheelchair. There we'd sit for 45
minutes, three times per week. The silence was probably more painful for me than it wasfor her. I, after all, felt a responsibility to somehow change her. She seemed only dimly
aware of my existence.
Eventually I began to speculate out loud about what it might be like to be her, locked up
in a psych ward and having an attempt at psychotherapy inflicted upon her by a young
know it all. When she couldn't take any more of my mistaken speculations Rebecca
would mumble corrections. This formed the early foundation of our relationship. Over
time she told me a great deal about what her reality was like. One event stands out in mymind. About six months into our therapy Rebecca was walking down the hall of thehospital. She was panic stricken when she saw a woman wearing a turquoise necklacethat looked identical to the one that Rebecca was wearing that day. Although theirappearances had little else in common, Rebecca had concluded that the other woman
was Rebecca herself. One thing was identical- the necklace- hence they must be identical
people. So Rebecca believed that she was approaching herself in the hallway and it was
too much for her to deal with.
Rebecca improved pretty dramatically over the year that I treated her.
While this goes against the prevailing beliefs of modern psychiatry, her recovery took
place without the use of any medications. When the time came for me to leave thehospital that she was living in, she regressed dramatically. By the time that I departed
she had become catatonic again. Several years later I heard from the therapist that had
assumed her care. Rebecca had pulled out of that catatonic episode pretty quickly. She
had eventually left the hospital and had recently married.
George was stuck. He had rubbed his hands through his rats-nest of a beard and along hair had come out. As he held this single hair out in front of him I could see hisanxiety mounting. He knew that he had to do something with it but his brain would notcooperate with the process of generating options and selecting between them. When I
finally said "why don't you just put that hair in the ashtray" he was visibly relieved.
When George was a little better he began to tell me what it had been like to be deeply
psychotic. He had been sure that if he ate the flesh of an animal he would, quite
literally, turn into that animal. "I used to fall for that one all the time", he said, as
though the idea was just waiting out there for anyone to trip on.
Samantha was yet another obese woman with only a few remaining teeth who had
suffered from schizophrenia for many years. She told me that when she had tried to live

by herself it had just been too much for her to handle. Samantha was absolutely
convinced that people came into her apartment at night and cut pieces of meat off fromher to sell at the neighborhood grocery stores or fast food restaurants. "Oh Dr.
Turnquist, when I'd go by a Wendy's I'd just shudder" she exclaimed.
Samantha also believed that she "grew extra arms out of her back" each night but wassure that the people who lived in her mattress cut them off. She always complained that
her medication caused her to have yellow snakes living inside of her. Her poor dentition
was nicely handled through her delusional system. Not only did she have teeth- she hadlots of them. In fact she believed that she had three complete sets of teeth waiting tocome in. She said that the third set was a full six inches long. I tried to figure out withher exactly how far up in the skull a set of six inch teeth would have to extend but thatline of questioning went nowhere. Her delusional system was so complex andentrenched that putting a dent in it seemed impossible.
Like other people with schizophrenia, Samantha had some peculiar tastes in fashion.
While she weighed at least 250 pounds she would somehow manage to squeeze herself
into size 8 shorts. The effect was striking, to say the least.
I've been surprised to see a similar style taking hold among the non-mentally ill young
women of today. The idea of wearing clothes that are so tight that bulges of fat explodefrom gaps between shorts and tops seems to be catching on. Maybe Samantha was on tosomething...
One time Samantha "eloped" from the hospital . Elopements were a big deal back then.
You never knew when or how these people would turn up, or what sort of things might
happen to them in the community. We sent out a Missing Persons report to the police
but she wasn't located. A week passed and I'd just about given up on ever seeing her
again. Then, on a trip to court in Minneapolis, I happened to be looking down into thecentral commons area of the county government center. There was Samantha, sprawled
out on a chair and smoking a big maduro cigar. I brought two deputies downstairs to
help apprehend her, anticipating that she might put up a fight. She didn't seem at all
surprised to see me there and came along willingly. I think that her "vacation" hadgone on long enough and she'd gone to the one place where she knew that she wouldbe "caught" and returned to The Unit. Of course, these days smoking a cigar in thegovernment center would be looked on as a much more serious offence than runningaway from a psychiatric hospital.
It was common back then for me to write bogus Doctor's Orders for "cosmetology
consults". So many women with disorganized schizophrenia would wear absolutely
garish make-up in a sad but often comical attempt to be beautiful. One woman wasalways ripping up the seams of her dresses and reconnecting them with the pull tops ofsoda pop cans. But one of the finest beauty statements of all was made by a VISITOR to

The Unit. A young woman came in to see her boyfriend, who had been recently
committed to the hospital. There was something striking about her appearance so I had
to go into the smoking room for a closer look. To my amazement I found that she had
Superglued a stone to her cheek, right underneath her left eye.
Beauty is, indeed, in the eye of the beholder. But some of those eyes are connected to therest of the brain in strange ways.
Georgia was another woman with unique fashion sense. Her peculiar fashion
statement was to wear summer clothing throughout the winter and vice versa. In thesummer it was painful to watch her wearing a heavy coat and hat on stiflingly hot days.
The Unit was, unfortunately, not air conditioned.
Georgia was incredibly hard to form a relationship with. She had somehow maintained
an ability to play the piano but attempts to engage her around music went nowhere.
Eventually it dawned on me that what Georgia absolutely could not stand was me
looking at her. Many of these folks are overcome with self-consciousness, even selfloathing. Being scrutinized by others, especially those in authority, can be too painful
for them to bear. Gradually we fell into a pattern where we could sit together for at leasta few minutes. Rather than sitting across from her I’d arrange the chairs so that we’dbe sitting side by side, looking out at the world together through the windows. I made apoint of never glancing at her for more than a second or two. That seemed to go a longway in terms of making my presence more tolerable for her.
While Georgia had been extremely disorganized for many years, she began to improvesignificantly when the new antipsychotic medicine Clozaril was introduced in the early
90’s. In fact she was one of the first patients that we had on that medicine. As her
thinking began to clear she tried to make some sense of what had happened to theprevious twenty years of her life. One day she revealed her theory. “I think what
happened was that one day I went on a trip to California- and I never came back” sheexplained. What a wonderful metaphor for losing one’s sense of self, even though she
meant this quite literally.
The version of our own lives that we create for ourselves via the memory process is always
subject to distortion, whether we suffer from a mental illness or not. My own recollectionsof who I was and how I treated people back then are relatively unchanging. The rare
therapeutic successes are given much more emphasis in my memories than are my many
disappointments. But even I must admit that there were some patients who, despite my best
intentions, seemed to despise me and everything that I stood for. In some of their realities I
was a demon, a tormenter, or worse.
Bubba wasn’t even one of my patients. He was treated by one of the long series of otherpsychiatrists that I partnered with on The Unit. But Bubba hated me nonetheless.

“Here comes Hitler’s son” he’d yell whenever he saw me in the halls. He was an elderlyman ( with no teeth, of course) but he’d still get rambunctious on occasion. For somereason when he’d "go off" I was his favorite target. Before I got to The Unit his
aggressive behaviors usually were met with “take downs” in which a number of staff
would rush him, bring him down to the floor, and then inject him with tranquilizers. He
would then be strapped to a gurney and transported up to one of the seclusion rooms
upstairs, where he'd remain as long as necessary to calm down. To their credit, the staff
had the art of the “take down” down to a science. Take downs were a regular part oflife on The Unit.
When Bubba would come after me it was an easy matter to stay out of his reach. He had
to be at least seventy and wasn't in the best of shape. If I walked at even a brisk pace I
could easily stay a few steps ahead of him. The whole take down, injection, andseclusion routine was not one that I was comfortable with so I’d just let Bubba chaseme for a minute or two until he’d blown off some steam. For some strange reason
though, I used to get the giggles when people were really angry with me. So a common
sight on The Unit involved Bubba chasing after me, cursing and flailing his arms
wildly, with me giggling like a madman a few steps ahead of him. He never did lay afinger on me, although I’m sure that there were times when he could have caught meby surprise. By the end of my stay on The Unit we had gone from secluding someone on
nearly a daily basis to averaging about one seclusion per year.
Sophie was another woman who detested me. Her standard greeting was“ who let you out of Stillwater Prison you fucking asshole?” Many times she would
loudly command her hallucinated allies to come after me. “ Get that motherfucker. Kill
him. Cut off his head and shit down his neck” she’d cry. Even though I was pretty surethat she was the crazy one of the two of us it was still a bit disconcerting to hear hercommands.
LuAnne came through The Unit several times. When she was stabilized on medications
she was quite sweet-natured and friendly with me. When she was off of her medicine
and decompensated she was about as vile as a human could be. One day I heard that
she was coming back in. She had rushed out to her sidewalk and clotheslined a sevenyear old girl who was innocently riding by on her bicycle. I heard LuAnne well before I
saw her. "Where is that horse-piss Ethiopian Doctor?", she hollered. "Wait til I get myhands on that German-Catholic son of a bitch". Her rants about people being"German-Catholics" were pretty standard for her but thinking that I was "Ethiopian"came out of the blue. As much as she despised me, I must reluctantly admit that I liked
the nasty, demeaning version of LuAnne better than the syrupy sweet person that she
presented herself as when she was "better". Maybe it was that she was more genuine
and authentic when she was ill. Perhaps her negative distortions of me were easier todismiss as "crazy" than when she saw me as much better than I actually was.

Whenever a patient was put into seclusion it was the psychiatrist’s job to see them and to
fill out a form justifying the fact that they had been secluded. Whether we agreed with thedecision to use seclusion made little difference. If a Doctor didn’t back up the decisions of
his nursing staff there’d be hell to pay. Nurses can make a Doctor's life about as miserable
as they want to, when it really comes down to it.
During my first weeks on The Unit Greg, one of the younger male patients withdisorganized schizophrenia, had made a clumsy sexual advance towards one of thewomen. In fact, “clumsy” would be a generous characterization of his actions. He had
simply walked into her room as she lay in bed and laid on top of her. No attempts togrope, fondle, or even kiss her were involved. He just laid on her. The nurses reacted toher resulting screams in a predictable way. This was seen as a sexual assault and met
with the standard take down, Haldol injection, and trip upstairs to a seclusion room.
By the time that I arrived at the seclusion room Greg was completely calm and a little
embarrassed about what he’d done. I decided that rather than give him yet anotherlecture about how “inappropriate” his behavior had been (the nurses had more thancovered that territory) I’d talk to him about how his strategy with the female in question
had been doomed from the start. I explained how women liked to be treated with respect,
how he should try to show some interest in her as a person if he really wanted to have arelationship with her. “Besides”, I added with a grin, “ I’ve tried that strategy of justlaying on them many times. It never works for me and I'm sure it won't work for you
either”. Greg was forced to smile at the image of me trying his strategy and I think that
he got the points that I was trying to make. He came back to The Unit with me and nevertried anything like that again. Upon return to The Unit, however, I was shocked tolearn that the seclusion room upstairs was wired for sound. The nurses on The Unit
had all heard the way their new Doctor had dealt with Greg’s misbehaviors and weredoubled up with laughter.

When the weather was cooperative I tried to give my patients a choice of where we'dspend our time together. Some preferred my office, others liked to go for walks. Many of
the older folks liked to sit on the porch outside of The Unit. Elmer was a terribly
anxious old widower who really didn't want to face leaving. I had sat on the porch withhim on many occasions, talking about the loss of his wife and what his life might be likewhen he went off to live in the nursing home that was being arranged for him.
Somehow, in the days prior to his departure he managed to get out onto the porch byhimself. Someone must have left the door unlocked. Elmer decided that he would makehis best bid to stay. A nurse came running down to my office and exclaimed "Elmer's
on the porch-he says he's going to kill himself". When I got there he was hanging fromthe railing with both hands. "I'm gonna jump- I swear I'll do it" he said. It was aserious moment and his emotions were very real to him yet I had to struggle to keepfrom laughing. Elmer's feet were hanging less than a foot off the ground. As manytimes as he'd sat out there he apparently had never realized that the porch was only
elevated about six feet.
Gene was brought to psychiatric attention after shooting at a neighborhood teenager
with his twelve gauge shotgun. As I tried to figure out why a crusty old bachelor would
suddenly start shooting at the neighbor kids a bizarre delusional world emerged. Genewas certain that the neighbor boy was shooting at him with a bow and arrows. While hehad never actually seen one of these arrows, he "sensed them" as they went bye. Anysuggestion that they might not have been "real" was regarded as nonsense. But theinvisible arrows weren't even the real problem.
Gene believed that someone was causing him to have a tickling sensation in his rectum.
He didn't come right out and say it but I was pretty sure that this sensation had anerotic quality to it. His tormenters somehow managed to do this to him with their
television remote controls. Gene lived at least a quarter mile away from his nearest
neighbor. Discussion of the actual range of these devices, and their inability to travel
through solid walls, was unproductive. But he was interested in my questions about
how and why this "tickling of his butthole" was still continuing. This was the third
psychiatric facility he'd been in since the police removed him from his home and thetickling sensations had never stopped. How, I wondered, had his tormenters managed
to track him around the entire State? Gene motioned for me to come closer andwhispered "Depth Finders ".
Another man was absolutely convinced that he was being "followed by a Lazy Ike thatmeant to kill him". To the nonfishermen, a Lazy Ike is a fishing lure that is about four
inches long and known for its side-to-side wobbling action. How or why the lure wasfollowing this gentleman may never be known.
Cynthia complained that "people keep talking to me in foreign duck voices". "I'm ahundred and eighty years old" she said. "If I took off all this Vaseline you'd see all of
the wrinkles". "That psychologist of yours almost killed me to death". " I won 100
million dollars doing a crossword puzzle- I made my whole neighborhood rich!". She
also said that she was rich as a result of an accident in Florida in which she was "runover by a train and killed”. Cynthia demanded an immediate discharge one day. “ Thenotary public signed the forms - once a notary signs something it is the law” sheclaimed. One hot day in June she was wearing a leather coat and gloves. She explainedthat the gloves were necessary “because there are things coming out of my fingers”.
Cynthia was hard to confront about any behavioral problems. When I once tried to tellher how loud and disruptive she’d been on The Unit that day the excuses came fasterthan I could address them. “I was hypnotized in the bathroom...I have to be loud - ithelps my neck...I was in the choir... most of my family is deaf...I had to be loud for mythyroid”. Finally she said “Why should I change? - it works”.

Occasionally we’d have police officers on the ward , usually for security reasons but
sometimes to serve warrants or to transport people to court. “ I’m going to be apoliceman again someday”. Cynthia exclaimed. “I’m going to really kick the shit out ofsome people”.
We used to dread the Publisher's Clearing House sweepstakes. They used to mail out
official looking letters to just about everyone in the country. The letters announced thatthe recipient had won huge prizes, prizes in the millions of dollars. Of course if you
read them carefully they actually said that you won IF you had the winning number.
But for our folks that sort of careful scrutiny was impossible. They simply concluded
that they had won the sweepstakes and were now millionaires. They wanted to get on
with the business of spending their winnings as soon as possible. One gentleman had
plane tickets to Hawaii hand - delivered to The Unit. Our unpleasant task involved
having to go over the forms with them to explain how it was that they really hadn't won.
Predictably, some people thought that we were lying to them so that we could keep their
Publisher's Clearing House money for ourselves.
Wishes, conscious or otherwise, often provide the seed that delusions crystallize around.
Sometimes the wishes are pretty transparent.
Luke had been a puzzle to the neighbors in his apartment building. They would often
see what appeared to be trash outside the door to his apartment. After a while, though,they realized that it was always the same things that he’d leave there. Empty beer cansand empty cigarette packages. Luke was convinced that if he wished hard enough somebenevolent force- perhaps part good fairy, part deliveryman - would refill these empty
containers. His frustration mounted as time went by without his ever receiving a refill
visit.
Luke’s delusion was pretty easy to understand. What child hasn’t wished for some magicalbeing to bring them the sorts of gifts that they would get all of the time if only the grown
ups would appreciate them more? Tooth Fairies, Easter Bunnies, Santa Claus. These are alla part of the reality that many of us live in as children. Sometimes we carry these ideas on
through adulthood but the topic gets a little sensitive when it is our adult beliefs that are
scrutinized.

Is the standard image of “Santa Claus” really that different than that of “God” that mostWesterners carry around with them? Older white men with gray hair and beards that makes
wishes come true if you're good- and if you believe. One is thought of as chubbier andmore likely to wear red than the other but there are a lot of similarities. Once again an
objective visitor from another planet might be forced to conclude that the differences
between “normal” humans and those with mental illnesses are not quite as great as the“normal” humans would like to believe.
Monica’s wish was easily visible to me but completely out of her awareness. She came to
The Unit only after extensive efforts to have her sent to a specialized “hypoallergenic
porcelain environment in Texas” had fallen through due to financial issues. Monica
was billed as having “environmental allergies” of the most severe kind possible. She
had become “allergic” to just about everything. Her allergies in her home had become
so severe that the family had shelled out big dollars to have the entire house treated withozone in a strange attempt to neutralize the allergens. Then she became “allergic” toeverything that the ozone had touched. Since this entailed the entire house and all of
their belongings there was no way that she could safely live in her own home.
She literally could not tolerate being in the same room with me. She always complainedthat I must be wearing “hair tonic” or other such chemicals because it was hard forher to breath whenever I tried to interview her. Monica insisted that she could not sleep
in a regular bed and certainly could not tolerate roommates. The only foods that she
was not allergic to were walleyed pike and brown rice. Neither of those showed up
regularly on The Unit's menu. The nurses were certain that Monica would starve todeath if we didn’t somehow arrange to get her “safe foods” brought in for her.
I was pretty convinced that despite what her various “allergists” had found, Monica’s
problems went a little beyond allergies. The certainty with which she clung to her beliefs
seemed to reveal their psychotic nature. I arranged for her to be faced with choices. She
could choose between the regular hospital bed that she was "allergic" to or she wasfree to sleep on the two hard wooden chairs that she said were the only “bed” that she
could tolerate. Similarly, she could try to avoid eating except on the rare occasions when
her fish and rice were brought in by her family. In our meetings her complaints ofallergies were given little attention. We both agreed that I, as a psychiatrist, would be
generally useless when it came to dealing with complicated things like allergic
responses. Instead we would talk about how the rest of her life was going.
What Monica really was wishing for, and communicating so effectively via her
symptoms, was to be away from her husband. The children had recently left the nest
and some of the long neglected relationship problems had begun to surface. The
husband was too powerful and rational to be dealt with directly. So she became allergic
to everything that he had ever touched. It was later revealed that she believed that she
had even become allergic to his person. When the house had become off limits as aresult of the ozone treatments she had lived in her car for a while, then decided to go
stay at a family cabin. As she approached the cabin, however, she became increasingly
anxious and short of breath. She knew that her husband was there waiting. Ultimately
she came to the conclusion that her allergies made it physically impossible for her tocome within a two mile radius of the man.

Within a short time of arriving on The Unit Monica was eating regular foods andsleeping in a bed again. The complaints of allergies cropped up regularly, but weren’t
as severe. In addition to her odd ideas and relationship problems, she had a full fledged
Major Depression. As depressions sometimes do, hers had also made her psychotic.
Treating her depression with medicine and talking to her about the new phase of herlife that she was entering seemed to produce some benefits. But even as she improved
she did not want to return to her family home. The chaos on The Unit, even Martin
trying to hump her in the hall one day, did nothing to ready her for the return home.
Many of us psychiatrists are experts at claiming responsibility after the fact when ourpatients improve. Maybe it is our medications, perhaps the insightful things that we say, but
we can usually convince ourselves that we were the difference. The facts that most of theseillnesses will sometimes get better without treatment and that people do have recuperative
powers of their own are often overlooked. When the patients don’t improve we can always
fall back on the idea of “ The Negative Therapeutic Reaction”. That theory holds, inessence, that our therapy is so good that the patient is not ready to handle all of the resulting
improvements. So they get worse.
In Monica’s case it was probably not anything that I said or did that convinced her that
it was time to get on with her life. That turning point occurred the night one of thecrazier female patients snuck into her room. Monica awoke to find the woman trying to
jam some feces - soiled toilet paper down her throat. The allergies were better but thiswas clearly more than she could handle. Within a week she was home with her
husband, along with a referral for marital counseling.
It doesn't show up in the literature much but a lot of psychotic people have trouble withmirrors. Our nervous systems are so attuned to human faces that all sorts of problems canarise around them, even our own. Many people with schizophrenia can look at their own
face in a mirror but distort their reflected images. The image in the mirror is often
experienced as alive in its own right and may move, grimace, change shapes, or even speak.
Calvin would help me to teach the medical students about mirrors. We'd walk down tothe end of the hall, where someone had mounted a full length mirror for some reason.
He'd stand motionless before it for a few moments, then exclaim excitedly, "see, see,
there it goes". He'd point to the parts of his face that were changing. Of course there
was nothing to see from our vantage point. But Calvin would see his face changing tothat of Marilyn Monroe or another actress named Samantha Eggars. Perhaps related
to the peculiarities of his own experiences with faces, Calvin would often greet me in an
odd way when I'd come to The Unit. "Hi Doctor- Its me, Calvin" he'd say. Even after
I'd known him for two years he still introduced himself to me in that manner. "Ofcourse it's you Calvin", I'd sometimes reply "who else would it be?"Sometimes we'd see patients sitting in front of those mirrors for hours at a time. Yearsearlier an outpatient had told me "sorry I'm late Doc- I got stuck in the mirror". At thetime I hadn't known just how literally he had meant this.
The extreme importance that our nervous system places on human faces comes out in otherfunny ways. Most of us have had the experience of physiognomization. This is ourtendency to see faces even where they do not exist. Children may "see" Abe Lincoln in acloud. Patients may see faces everywhere, in the textured patterns of their walls or ceilings
or in a flickering fire. Psychotic people may see human faces distorted to look like the facesof animals. And the task of correctly deciphering emotional expressions on human faces
may be an impossibility for some patients.
Stella came to The Unit during my eighth year there. She couldn't have come at a better
time. By then I was growing tired and a bit jaded. A couple of unexpected patient deaths
had taken their toll as well. I was coming to believe that I had heard just about every
crazy idea a person could have. "Rays", demons, witches, computers, spies, Satan,bodies that wouldn't stay together properly- they were all just sounding like variations
on familiar themes that I'd heard too many times before. Stella reminded me that there
is simply no limit to the realities the human mind can create.
Stella had a special thing about bears, especially white bears. One day as we sat on theporch she looked up at a cloud overhead and said "there's a bear right there... you haveto shoot 'em - you just have to.. I've been shooting those things for ten years. If you
don't shoot them they die and rot and the blood falls all over you". Stella believed that
she and I were not strangers to each other. We had lived as disembodied heads on the
tongue of a giant white bear for some 63 years, she said.
Stella believed that there were special "holes" to be found throughout the earth. Those"holes" were tricky, she explained. You could fall into one and come up in China orother exotic places. And the giant snakes that lived in the holes were always a potential
problem.
On one occasion I was feeling pretty puzzled as we'd been together for almost ten
minutes and there's been no talk of the bears. She motioned me closer and explained"There was more than one Hitler, you know. He had a family. They changed theirnames but they're still around.".
Once Stella calmly told me that "her body had been replaced". "The new one likes to eat
all the time" she complained. "They put a pig's nest in me but maybe my brain and eyes
are worth saving". Stella said that she was in a State Hospital in Africa. "A spirit cameinto my head and made me a scientist" she claimed, then without a pause, she looked atme quizzically and asked "why did you put that rope around the baby's neck?". She
accused me of “reading her mind and controlling the weather”. Her comments often
seemed like they must have some symbolic meaning for her but as soon as I would startto speculate about what that meaning might be something else would come up. Stella
could always disarm me by producing a nonstop barrage of bizarre comments.
My notes from one session with Stella report that she had left me with my head shaking
and my jaw agape. She had stared by telling me that she’d like to go home as soon as
possible. I’d asked if she felt that it would be safe to go home.
“Well, it might not be that safe... there are a lot of bears in the neighborhood - I might
have to do a lot of shooting to protect myself. I was a sheriff in Oklahoma and I cameacross three men who had killed each other so I took their guns...a lot of the neighbors
give me guns too. I have a whole cabinet full of them. You need a lot of guns when
there are so many bears around”. The bears of this day were described as being “about
twelve feet tall with big scary brown eyes”. She said that she had fallen into a hole inher back yard and there were more than 5000 bears underneath her property. Stella
explained how tightly packed these bears were, standing up to demonstrate that they had
to keep there arms held tightly against their sides and how they could only step forward
a few inches at a time.
“They’re packed in so tight they have to sleep standing up... when I fell in there I had tosleep on their heads. Usually I slept on the bigger ones. I was in a fire in a nursing
home and it turned my skin completely black. The only thing that made my skin white
again was sleeping on those bears. I used to work with a woman named Lola. Lola’s
skin was black too. But she got some piss on her and it turns out her skin wasn’t blackafter all...
My understanding was that Stella had lived with a husband and a son but she
maintained that the people that she lived with were not related to her in any way. I asked
how many children she had had. “ They’re all dead” she replied. I don’t remember halfof them. I had 45 of them. It was hard to feed them all so we’d just pump their stomachs
up with air so they wouldn’t have to eat.”
Stella mentioned that she had had her head cut off when she was ten years old. “I’ve
had four or five bodies since then - some of them have been men...the right side of myhead is actually a man named Bob... A man with brown eyes came into my room lastnight and pulled at my tit with a pliers”. She looked at me earnestly and asked “well,
don’t you think that would have to be a bear?” I always imagined that, for Stella, thebears were a symbolic representation of the men that she actually lived with.
Dangerous, cruel brutes who were too mean to be human. Creatures that she would , at
one level, destroy if she had the means to do it. But she was totally uninterested in myinsights. For her, the bears were not something that symbolized someone or somethingelse. They were completely "real". If I couldn't see that then I must be crazy.

People that haven't spent a lot of time with psychotic people often have a hard time withstories like those related here. They assume that the person cannot truly believe things thatare this bizarre and outlandish. " They've got to be putting you on", they'll argue. "How
could anybody actually believe that that is true?" Or they will reluctantly conclude that thepatient is telling the truth as they see it but focus on the fact that people with mental
illnesses are just qualitatively different than other humans. People who have been in thebusiness, though, know that these are the realities that truly exist for these people. Many
also become aware that, as strange as these patients seem, their struggles and emotions are
the same ones that all humans must deal with at some time and in some way.
Derrick was a very religious man. In fact he talked to God regularly and directly andGod talked back. Derrick's world was populated by demons too. Sometimes God gave
him commands about what he must do to prove his basic goodness, to show that thedemons were not winning the battle for his soul. Unfortunately, one of God'scommands was that Derrick must remove one of his eyes. Something about having seensomething offensive was involved. So Derrick removed one of his own eyes with apencil. As I was sitting with him one day, trying to understand how he could dosomething that horrible to himself, Derrick looked down into the cup of coffee that I
had given him. Floating on the surface was a tiny piece of ash from his cigarette. He
looked at me calmly and, pointing at the bit of ash, said " why there's a demon rightthere". He explained that if God commanded him to remove his other eye in order toprove that he was not allied with the demon in the coffee cup he would do so without
any hesitation whatsoever. I knew that he was telling me the truth.
We psychiatrists are reported to have one of the highest suicide rates of any of theprofessions. There are a lot of reasons for this. Having to make reasonable predictions
about what psychotic or disturbed people are likely to do next is a hard business. We areoften in the position of having to determine if it is safe to return these people to thecommunity and, by their very nature, the severely mentally ill are often quite unpredictable.
There are never guarantees that how a patient behaves in the hospital will correlate with
their behavior after they've left. So disaster is always lurking around the corner in the formof suicides, violence, or psychotic decompensations. If negative outcomes occur there isalways the chance that the psychiatrist will be blamed or sued, in addition to the guilty
feelings that we inflict on ourselves. This would wear on anyone. And has beenemphasized elsewhere, prolonged exposure to stress hormones frequently leads to brainchanges that cause depression and anxiety. Just because we know about these emotional
reactions doesn't mean that we're immune to them.
The more significant reason for our elevated rate of killing ourselves is more complex.
When one is around psychotic people long enough it becomes apparent that each and every
one of them creates their own individual reality. Of course all humans do this. It’s just thatthe process becomes more visible when the realities that are created are so different. Being
experienced in so many vastly different ways by so many people is hard on thepsychiatrist's self-image. Strangely enough, being seen in a very negative and distorted way
is easier to deal with emotionally. If someone believes that we are Hitler or an agent in the"British Secret Service" those distortions are easy to dismiss as the output of a disturbed
mind. It is when we are seen in inflated terms, as better than we actually are, that theresulting emotions become harder to deal with.
All of us, whether mentally ill or "sane", must deal with the idealized version of ourselvesthat we carry with us at all times. Throughout our lives we form an image of what weshould be like. What we should look like, how we should conduct ourselves, what weshould accomplish, and where we should rate in comparison to other humans are all
ongoing creations of our nervous system. The inevitable comparisons of our actual selvesto the inflated version are a major source of the pain of being human. Psychotic people may
try to solve this problem by simply disavowing any parts of themselves that don't match up
to the ideal. They can truly believe that they are beautiful, powerful, loved, or important in
the face of massive evidence to the contrary. It is harder for the rest of us.
When patients, staff, or families react to psychiatrists as though we are wiser, morehumane, or better healers than we actually are (and that is a daily occurrence for many ofus) those distortions resonate with our grandiose versions of ourselves. These positive
distortions are much harder to dismiss since they are so concordant with our secret viewsof ourselves and what we should be.
The disparity between what we are actually capable of doing to help people and the
expectations that are held for us-by others but especially by ourselves- can become too
painful for us to deal with. Suicide, substance abuse, and a desire to minimize any contact
with patients are common outcomes for psychiatrists that cannot effectively come to termswith the fact that we are far from being the superior humans that we believe we should be.
Yet without that naive sense of grandiosity we may not have the energy or the will to makethe attempt to help others in the first place.
So perhaps when we look in the mirror and see a larger amount of arrogance,
ineffectiveness, or self-importance than we'd like to we can somehow forgive ourselves
these limitations. After all, rising above our primate natures in an effort to care for otherhumans is-at a most basic level- a stunning achievement for any person. If we aresuccessful in helping even a handful of other humans to have a richer, more satisfying timeon this planet doesn't that make our own lives worthwhile?
Hurtling through space at mind-boggling speeds without any real sense of where we'regoing or why can be nerve-wracking for any human. It's even worse when we expect that
we should be able to make some sense out of something far beyond the reach of ourcapacity for comprehension. Just doing the best we can in spite of our limitations is about
the most we can expect of ourselves- or anyone else. So, like all humans, we shrinks reallyshould lighten up a bit and enjoy the ride.