The Naked Lady Who Stood on Her Head (3 page)

He stopped pacing and went into lecture mode. He said that transference was one of the most important aspects of insight-oriented psychotherapy. It meant that the patient was transferring feelings she had toward a parent or authority figure onto the therapist. Therapists who can remain neutral and nonjudgmental—suppressing their own issues and emotional reactions during the therapy—allow the patient to fill in what they imagine to be the therapist’s reaction. When the time comes for the therapist to point out the reality of the relationship, the patient can gain insight into her distortions and realize how she transfers past distortions onto other relationships in her life. With the therapist’s help, the patient can come to grips with this pattern, put her distortions into perspective, and move on.

I understood the lecture on transference, just as I had the first three times I’d heard it. And as for Lochton’s explanations about Sherry’s early-childhood losses, they were plausible—maybe she was still hiding something from me.

Before the next session on Friday, I had decided to focus on Sherry’s self-destructive barhopping behavior and try to help her to stop. I was taken aback when Sherry showed up dressed like a prostitute.

She struggled to sit down in her tight miniskirt and started talking. “I want to thank you, Gary, for listening to me on Wednesday and helping me to stop doing what I was doing. It was crazy, and I know that you really do care about me.”

“I’m relieved you’ve stopped. How are you feeling?” I asked.

“You know the answer to that. It’s our little secret.” She winked, as if there was some inside joke between us.

“What do you mean?”

She didn’t say anything, just smiled.

“I thought we were beyond secrets, Sherry. For psychotherapy to work, you have to try to tell me what’s on your mind.”

She finally said, “But you know what’s on my mind—every time you look into my eyes.” She reached into her purse. “Here’s a little thank-you for our last session. I hope you enjoyed it as much as I did.” She handed me a gift and darted out of the office before I could say anything.

The gift was beautifully wrapped. I wasn’t sure what to do, so I opened it. Inside was a Rolex watch—a real one. I ran into the hall and looked toward the elevator, but she was already gone.

A basic tenet of psychotherapy is to help people put feelings into words, not action. Sherry had crossed the line with the watch. There’s a general rule in therapy that no gifts can be accepted. I called Lochton for advice, and he just told me to return the watch and explore the patient’s motivation for the gift. He also said I shouldn’t worry about her mini-skirts and plunging necklines. They were just expressions of her transference. It really had nothing to do with me. It was her father that she was pursuing.

At our next session, Sherry entered my office in a red cocktail dress and matching pumps. She seemed to bubble with joy—like a newlywed in love. As she sat down, she saw the Rolex on the coffee table and became serious.

I pushed the watch toward her and said, “Sherry, there are rules in therapy. No gifts, no—”

She interrupted angrily, “You’re returning my watch? Fine.” She threw the watch into her bag. “And how dare you?
You
seduced
me
.”

“What are you talking about?”

“Oh, please. You stared into my eyes and had sex with me. You and your sexy stare—as far as I know, I could be pregnant from your raping, peering eyes.”

I had been taught to maintain eye contact as patients spoke, as a way to express interest and empathy and to try to listen and not interrupt. I was dumbfounded. Sherry had experienced my eye contact as a sexual assault. She was more than a neurotic housewife; she was talking crazy. Having sexual intercourse by looking into someone’s eyes sounded more
like a psychotic losing touch with reality than an angst-ridden woman expressing her neurotic woes.

“Let’s slow down here, Sherry,” I stammered.

She stood up and inched toward the coffee table. “You should have thought about that before you looked into my eyes.”

Confused, I stood up too. My heart was pounding as she moved forward around the coffee table, and I backed away toward the door. Was she going to grab me? Embrace me? She was acting insane, and I had lost control of the session.

“Sherry, sit down. Let’s talk about this.” My attempt to bring order back to the session only worsened the situation.

Her face reddened with rage. “How dare you give me back my gift. That came from my heart.”

“Sherry, I didn’t mean to hurt you. It’s just that there are rules for therapy—”

“Therapy?” she shouted. Suddenly, she lunged forward and slapped my face, hard. She was about to strike me again when I grabbed her wrist and said, “That’s enough! This meeting is over.” I quickly left the office and retreated down the hall.

Fortunately, the clinic secretary was at her desk. I asked her to check on Sherry and escort her from the clinic. After ducking into another office to hide, I heard Sherry stomp down the hallway in a huff.

I was shaken. Was this a rite of passage for a neophyte psychiatrist, or had I made some major tactical error? I had never been hit by a patient, despite numerous threats. I recalled a chronic schizophrenic that I sent to the state hospital the previous month calling out to me, “I’ll get back at you for this, Small. I never forget!” But somehow he didn’t feel as threatening. With Sherry, I never saw it coming. I let her chase me out of my own office. Could I continue treating her? Would she try to slap me again next time? I needed some supervision, but I no longer thought Lochton was the guy to help. In fact, I was angry at him. Following his advice had gotten me into this mess.

There were many skilled therapy supervisors at Mass General who knew about tough patients and tricky supervision situations. I was able
to schedule some time the next day with Joe Sandler, a seasoned analyst and psychodynamic therapist who specialized in borderline and psychotic patients. I had attended a few of his seminars and liked his style. He was a cross between an opinionated Irish bartender and a caring Jewish mother.

Sandler agreed with what had become obvious to me since having my face slapped. Sherry was much sicker than either Lochton or I had appreciated. She was a borderline psychotic who could not tolerate the anxiety of probing psychotherapy. Borderlines are patients whose psychological state straddles the line between normal anxiety and psychosis. When under stress, they tend to distort reality and have delusions and hallucinations. All my delving into Sherry’s past and not answering any of her direct questions about me had pushed her into a psychotic delusion that I was having sex with her by looking into her eyes. She didn’t need probing; she needed support and nurturing.

Sandler suggested I take a closer look at Sherry’s medical history. I looked up her old hospital medical records and found that her lab tests were all normal, but she had never had a head CT scan or an electroencephalogram (EEG). It was a long shot, but maybe Sherry had a brain tumor or some kind of neurological problem that was contributing to her psychosis and erotomania.

I knew Sherry needed help, and I got some referrals for her in case she wouldn’t continue therapy with me. Despite my anxiety about working with her, I felt bolstered by my new supervision and wanted to try again.

After a week, I gave Sherry a call. I encouraged her to come back and talk about what happened. She was snippy at first but willing to listen. I told her that I really did want to help her and that a different approach might make sense at this point. But she would have to follow the rules—no hitting and no gifts. I told her that we would not need to explore her past so much but would look for ways to help her cope with the feelings that brought her to therapy in the first place—emptiness and loneliness. We could also slow things down and meet just once a week. I wanted her medical doctor to get some additional tests so we could possibly start her on some medication to help calm her nerves. Finally, I assured her I
would not stare into her eyes and reiterated that I had not meant to make her uncomfortable. I think she sensed I was back in the driver’s seat as her psychiatrist, and she agreed to come back.

Sherry returned to weekly therapy, and I started her on a low dose of an antipsychotic drug. It quickly dampened her eroticized transference delusion, and she also toned down her wardrobe.

“I don’t know what I was thinking, Dr. Small,” she said. “I was just stressed out because Eddie was traveling so much and you seemed to be interested in what I had to say.”

“I’m just glad you’re feeling better, Sherry.”

“I can’t believe how stupid I was going to that bar. I could have taken home an axe murderer or something.”

“I think the medicine is helping you cope better with your anxiety,” I said.

In the meantime, the results of her medical evaluation came back. Her EEG revealed no evidence of temporal-lobe epilepsy, a condition sometimes caused by a brain tumor under the temples, which can lead to personality changes and hypersexuality. Sherry did have a pattern of hypersexuality, but the scan ruled out a possible neurological explanation for her symptoms. A diagnosis of borderline personality disorder turned out to be the best explanation for her symptoms and her negative response to the insight-oriented psychotherapy Lochton had recommended.

Sherry continued to see me weekly for supportive psychotherapy and medication follow-up. In general, she was less anxious and seemed to have a good grip on reality. Whenever her husband would leave for an extended business trip, I would increase her dose of antipsychotic, and she didn’t relapse into her old barhopping behavior—as far as I knew. In fact, she was progressing so well that I started to delve a bit into her past, and she revealed that her parents had separated when she was twelve—Lochton had been partly right about her having an early trauma. But at the next session, Sherry showed up wearing a miniskirt and pumps, so I backed off digging into her early childhood, and focused on helping her cope with her current anxieties and fears. After another year in therapy with me, she decided to switch to someone in the suburbs near her home.

Part of me was sorry to see Sherry go because her therapy was finally going well and her life seemed to be relatively stable. Another part of me was relieved. I never forgot that slap, and I always had lingering fears that the slightest misstep on my part could tip her from reality into another psychotic delusion.

I realize now that what most disturbed me about working with Sherry was that my initial diagnosis had been so off the mark, and my supervisor had been clueless too. Week after week I sat in a tiny office with someone I thought I knew, who turned out to be somebody completely different—an unpredictable, seriously disturbed, and potentially dangerous woman. I followed Lochton’s advice and instructions even though they often felt wrong to me.

The “sexy stare” incident taught me a lot about trusting my own instincts as a therapist. The Loch Ness Monster had turned out to be partly right, but once I dropped him as a supervisor, I realized that nobody’s perfect—not even know-it-all professors who treat celebrities and politicians. Sherry’s slap in the face hurt, but it knocked the giggles out of me, and for the first time, I started to feel like a real psychiatrist.

Spring 1979

I WAS HALFWAY THROUGH A CROSSWORD
puzzle during a break in the psych residents’ coffee lounge. Mike Pierce had been the attending that day and was getting ready to head out. I had been on call for eleven hours and had thirteen more to go when we heard the familiar overhead page: “Psychiatry to room six.” When the security officers considered a new arrival particularly rambunctious, they whisked the patient immediately to room 6, where the feisty newcomer could be locked in for observation.

“Room six. You’re up, Small,” Mike said.

“Oh boy, my favorite,” I said.

“You may think room six is a bummer, but trust me, it is,” Mike said with a smirk.

“This’ll be a piece of cake,” I said, gripped with apprehension.

“No one will wait up for you,” Mike said as I left.

As I walked to the emergency room, several nurses raced by me. I passed a surgical resident bandaging the head of a crying teenage boy lying on one of several gurneys lining the hallway. Another doctor was
yelling for a crash cart. The E.R. was a cacophony of wailing patients and on-call doctors shouting orders at nurses and attendants—typical for a Wednesday evening.

My heart was pounding. I was eager to meet this new patient, but I was scared too. Room 6 was sometimes horrifying, almost always challenging, but never boring. Responding to a room 6 page could mean anything—an agitated schizophrenic killer with a hidden barbecue skewer, a suicidal bipolar with a secret bottle of Valium, or a heroin addict going into withdrawal and about to projectile vomit on you. Thanks to an unfortunate but traditional rite of passage in medical training, the doctors with the least experience—me, for instance—had to grapple with the most challenging and difficult patients.

To deal with what seemed like impossible situations, I often fell back on my textbook knowledge and tended to treat patients in a stilted, clinical way. Freud would have said I used intellectualization as a defense mechanism to cope with my anxiety about wanting to help my patients and not harm them. Like any doctor, I had the daunting task of trying to translate a massive amount of information into a simple diagnosis and treatment plan. Whatever defenses I was using in those days, my human side managed to slip out on occasion, and I think those moments of empathy were the ones that helped my patients the most. Later in my career, as I gained more experience and confidence, I became better at listening and understanding my patients.

By the time I reached the nurses’ station outside room 6, I was so anxious and worked up that Judy Nelson, the head nurse, gave me a tissue to wipe my brow. Judy had been an E.R. nurse for twelve years and had seen hundreds of green residents like me struggle with room 6. She was in her early thirties, divorced, and really pretty. She also had the perfect balance of poise and sarcasm. Whoever divorced her was an idiot.

Judy handed me the patient’s chart. “She’s a Jane Doe, around twenty. The cops picked her up babbling in the North End. I’ll have to remember that babbling’s a crime around here.”

Judy’s casual attitude calmed me down, and I scanned the chart. The police had found the patient disheveled and wandering the streets of Bos
ton’s North End, an Italian community less than a mile from the hospital. The emergency techs noted that she kept shrieking and pulling at her clothes during the ambulance ride over. Between screams she mumbled about how hot she was, although the outside temperature was in the forties. The techs had performed a brief examination and had found nothing abnormal, aside from her agitated and unusual behavior.

I walked down the hall to room 6. Unlike the other E.R. exam rooms, room 6 had a door with a window covered by a sliding wood panel so we could check on psych patients before entering. I slid back the panel and saw a petite girl who looked to be about nineteen or twenty, standing on her head, stark naked. It took a moment to register. I didn’t know whether to laugh or run. Before I slammed closed the wood panel, I did notice that she was balancing herself rather well. I turned and stared at the gurneys and patients in the hallway, trying to process what I had just seen.

“Are you all right, Dr. Small?” Judy asked.

“Fine. I just want to check something in her chart here before I go in.”

But I wasn’t fine. What did this naked headstand mean? Was there some psychological significance to it that I wasn’t getting? Was she trying to communicate something, or was she just completely out of her mind?

“Judy, could you call a couple of security guards down here in case I need them? Also, please grab a gown for the patient.”

I slid open the little window again. The patient was still doing a headstand and had a blank expression on her face as she stared toward the door. “Hello. My name is Dr. Small. I’m the psychiatrist on call tonight.”

No response.

“Can you hear me? I need to come in and ask you some questions,” I said.

Again, no response.

Okay, I was afraid to go in the room, and Judy was watching. Jane Doe’s bizarre behavior meant that anything could happen. She could become violent without warning. I imagined her lunging and trying to strangle me. On the other hand, her nakedness made her seem vulner
able, and she was probably scared too. I needed to interview her, but first I had to get into that room.

I took a few deep breaths and calmed down, recalling that sometimes simply showing a patient that the staff was in control helped avoid a scene. Finally, Judy came over with a gown and two security guards, Joe and Carl. Both were local guys who loved teasing the residents and giving us a hard time. Having them around made us feel safe if patients got out of control.

I spoke through the little window in the door. “I’m going to come into the room now with a nurse and some of our staff. I need you to stop standing on your head, please.” She didn’t move. I noticed her filthy, torn clothes in the corner of the room.

“We’re going to place a hospital gown on the gurney. You have a choice to either put it on yourself or let the nurse help you.” I had been taught that offering unpredictable psychotic patients a choice sometimes distracted them from their hallucinations or delusions, essentially tricking them into being more reasonable.

As Jane Doe continued to stare from her headstand, our troupe moved slowly into the room, which contained only a rolling stretcher and a metal chair. Judy led the way and placed the gown on the gurney. Carl and Joe took positions in the corners. I stood in front of the open door. Though I believed it was to block the patient from bolting from the room, I think now it was also, subconsciously, to allow me to make my own quick escape.

The strength-in-numbers tactic seemed to work. Judy moved toward the patient and gently helped her down from her headstand, as if she was spotting a gymnast. Judy spoke quietly as she assisted her with the gown, “You’re so lucky to have those pretty blond curls.” She escorted Ms. Doe to the gurney and said, “Sit down, sweetie, and get comfortable.”

I pulled up a chair and took a moment to observe the patient. Her hair was matted and dirty, and she had a butterfly tattoo on her ankle. “Can you tell me your name?” I got no response, so I followed with, “Do you know how you got here?”

She mumbled something about how hot it was.

“You’re right, it is warm in here,” I said. “Would you like me to get a fan?”

Blank stare and no reply.

“Is there someone I can call for you?”

The patient twitched for a moment, and I thought she was finally going to say something real, but still nothing. Joe and Carl were clearly amused by my futile queries but stifled their laughter. I didn’t dare look at Judy.

I was getting annoyed—I was trying to help this patient, not entertain the staff. After what seemed like an endless string of feeble attempts to get her to talk, I moved on to a physical exam and tentatively lifted her wrist to check her pulse. Her hand felt clammy. When I tapped her knees and ankles, her deep-tendon reflexes were normal. She wouldn’t cooperate for me to test her arm and leg strength, but other than a slightly rapid heart rate and low-grade fever, I couldn’t find anything physically wrong with her.

I had performed hundreds of physical exams, but this was the strangest one yet. Not only was I onstage for the staff, but my patient’s mind was off somewhere else. Because I couldn’t get her to walk for me, I wasn’t able to check her gait, which might have revealed various brain problems—wide-based could mean hydrocephalus, shuffling could indicate Parkinson’s disease—but I did know that she was neurologically quite capable of standing on her head. I knew she was out of touch with reality, but diagnostically, I was stumped.

People lose touch with reality for many reasons. Sometimes severe depression, stress, or trauma can push them over the edge and they escape into a distorted mental state that appears crazy to other people. But many mental symptoms, like psychosis, ultimately have a physical cause. In fact, many medical emergencies initially present themselves with
only
mental symptoms—delirium, confusion, depression, anxiety, psychosis, or panic attacks.

To help me remember the various physical causes of psychological symptoms, I had come up with my own mnemonic for some of the more common ones—“WHHIMP.” Each letter was the first initial for a
medical cause of delirium:
w
was for
W
ernicke’s encephalopathy, due to brain damage from chronic alcohol abuse. The
h
’s stood for a
h
ypertensive crisis (extremely high blood pressure causing an acute drop in brain blood flow) or
h
ypoglycemia or
h
yperglycemia from an imbalance in blood sugar.
I
reminded me that
i
ntracranial lesions such as strokes, tumors, and bleeds could be the culprit.
M
was for
m
eningitis and related infections of the brain and meninges, which coat the brain; and
p
was for
p
oisons, certainly high on the list of possibilities in a young person who might be experimenting with recreational drugs.

Jane Doe coughed suddenly, and we all jumped. She was looking straight at me now but still wasn’t talking. I moved my index finger from left to right in front of her face, but her eyes didn’t track it. I snapped my fingers in front of her eyes and got no response. When I suddenly clapped my hands, she flinched and blinked, so I did get some reaction. I ordered a CT scan to rule out a brain tumor or hemorrhage.

Her low-grade temperature could mean an infection, but she lacked the neck rigidity that was typical of meningitis. Her complaints about the heat and her nudity suggested possible heat intolerance due to an overactive thyroid, which the blood-screening tests would rule out. We needed a urine sample for a toxicology screen, but no way was she going to pee in a cup. She would have to be catheterized. To spare her the humiliation of two burly security guards holding her down, Judy shuffled us guys out of the room and enlisted the help of two female interns to catheterize her. She also drew blood for screening laboratory tests to make sure the patient didn’t have anemia, a thyroid disorder, or some other chemical imbalance that might be altering her mental state.

As I waited for the lab results, I decided to take another stab at an interview. The guards and I walked back into room 6, and I could tell that Joe and Carl were looking forward to seeing me get nowhere again. I tried to be casual with the patient and offered her a cup of orange juice. She finally seemed to respond to me. She slowly raised her hand for the cup. She took a small sip at first, then quickly gulped it all down.

“It looks like you were pretty thirsty,” I said. The staff smirked, anticipating yet another useless round of questions, but the patient’s demeanor
seemed to change—her blank stare was replaced by an inquisitive look. She scanned the room; her body tensed; her brow furrowed.

I felt like maybe we were getting somewhere, so I continued in my light tone, “Maybe we can talk now.”

Ms. Doe suddenly sat straight up and became aware of her scant attire. She wrapped her hospital gown tightly around her body and asked, “Where am I? Who are you? What the hell?”

I could sense that the team was impressed. I should have felt cocky that my astute, relentless, and well-timed interview skills had finally cracked this obstinate naked-lady case. I should have been proud that in my role as a psychiatrist, something I had said had actually gotten this delirious, mute woman to talk like a normal person. I mean, sure I had gone to school and read some books and aced some tests, but here I was in the real world, playing doctor, and I actually fixed somebody. Unfortunately, I had no idea what I had said that worked.

The patient held out her cup and said, “More.”

In an instant I realized it was nothing I’d said but something I’d done that got her to talk. More precisely, it was the orange juice. And that cup of OJ was also the key to what caused her bizarre behavior. Her blood sugar had obviously crashed, and she had been suffering from acute hypoglycemia.

Responding to the patient’s anxiety about her skimpy hospital gown, I asked Judy to get her a pair of scrubs to put on and escorted the security guards out of the room while Judy helped her change. I returned with another cup of orange juice and sat in the chair next to her gurney while she drank it. She was calmer now.

Again I told her I was Dr. Small and asked her about herself. Her name was Katie Genaro. She was nineteen and lived with her parents above their popular family bakery in the North End. She worked part-time as a waitress while taking acting classes and doing Equity theater whenever she could get a part.

I moved the conversation along to find out more about the cause of her delirium. “Katie, do you have any medical illnesses?” I asked.

“Why do you want to know?”

“Because you were brought to the hospital tonight, delirious. You’d been walking in the street babbling, and you only just now came out of your delirium when you drank some orange juice.”

“Shit. It’s my stupid diabetes again. I probably didn’t eat enough breakfast before taking my insulin shot.”