A psychiatry department whose founder personally recommends valium to come down from LSD and once took a year off to be team psychiatrist for a professional football team is bound to be interesting.
The founder, Dr. Banville, has always had a “desire to play with the big boys,” according to the occupational therapist. For the same reason, she adds, he always stands rather than sits during conferences. This is why he is intrigued by football.
Dr. Banville came from Los Angeles— where he was analyzed by someone famous and was himself psychoanalyst to the stars— to found this department on a hill overlooking the silent homes of retired Navy men and developers. He spirited away faculty from Yale and Washington University, and built a shiny labyrinth of labs.
David Miller, one of the psychiatry residents, complains that Dr. Banville spends too much time in his lab manufacturing psychedelics. “Dr. Banville’s rule of thumb,” he says, “is that a person who takes LSD only once every three months is probably sane. The only time I saw him on the bottom of a situation involving drugs was when an undergraduate came to the ward having taken a small bottle of an amphetamine derivative that Dr. Banville had managed to synthesize only a few pinches of.
“The undergraduate stayed up all of the first two nights wearing a cowboy hat and strumming rock and roll songs. I administered a huge dose of thorazine and he spent all of the third night lying on his bed whispering (you could hear him if you leaned very close) ‘Abbey Road’.”
Some people have charged that Dr. Banville gave speed to the professional football players to improve, or at least enliven, their 2-and-12 performance. David Miller counters that, judging from what he’s seen of the football players at department parties (they occasionally drop by), they’re all hopped up anyway and Banville may have administered a little speed only to withdraw them from it gradually.
Miller basically admires Dr. Banville for his off-the-field, clinical ability. One of Miller’s first patients was a teenage girl who alternated between thinking of herself as a woman and thinking of herself as a man, and who claimed that her parents were not her real parents but look-alike substitutes. Miller and the other ward staff could not get her to answer any questions sensibly, even though he went so far as to come in after hours and read poetry to her. She ran around the ward, nonsensical and shirtless, for a week before the case conference with Banville.
She sat at the conference like a prairie dog in a burrow. Banville looked into her eyes a long while and asked, “What are you afraid of? Is it machines, or the devil?”
“It’s the devil,” she said.
“Is he going to send you to hell?”
Banville looked genuinely terrified at this prospect. “What did you do wrong?” he asked.
She looked at him with fear and a little coyness, as if the two of them were Bonnie and Clyde. “I killed my parents.”
The spectators were awed by this intrusion of the Middle Ages into University Hospital, San Diego. Small, wiry, and double-crossing his legs, Dr. Banville sympathetically exposed the entire delusion. After she left the room, David Miller, who was responsible for treating her, asked Banville how he should go about this task.
“Seven to ten years of analysis,” he said. “During the first couple of years you may find yourself staying silent with her or throwing books at each other for hours on end.”
Dr. Caton, in a white coat the representative of psychopharmacology at the conference, strenuously disagreed about the treatment. “Six months of high-dose thorazine and she’ll be feeling fine,” he declared.
Dr. Caton has a round impish face which hovers like the moon above his ever-present white vestments. He ordinarily speaks in categories: “Depression of late middle age— shock therapy; paranoid schizophrenia— thorazine; sociopathy—unbeatable.”
His interviewing technique is less sympathetic than Banville’s. At the Veteran’s Hospital, his own parish, he once interviewed a clean-cut engineer who was as far gone as the teenage girl.
“When did you realize you were sick?” he asked the patient.
The engineer answered obliquely: “About six months ago, around the time of my divorce, I wasn’t sleeping so well.”
“Did you see or hear anything unusual?”
“I saw a crack on the wall one night that meant I was cracking up.”
“How do you suppose that crack got there?”
“I imagine that it, like the messages on TV, was planted by the CIA.”
Dr. Caton rolled his eyes up and snickered for the audience’s benefit. “What else has the CIA done to you?” he asked, and the engineer ticked off the elements of an intricate plot.
Afterwards, Dr. Caton summed up the case: “High-dose thorazine.”
For a while Dr. Caton’s after-hours pursuits were medico-legal. He sincerely believes that shock therapy is the best treatment for menopausal depression and that, other than such textbook truths, psychiatry is worthless.
Dr. Caton was disappointed, then, by two California laws—one making it difficult to administer shock therapy (one of the few helpful things a psychiatrist can do), and the other making the psychiatrist take responsibility for murders his patients have told him they were going to commit (one of the many things a psychiatrist cannot possibly do).
Before the shock therapy law was passed, the residents commonly heard Dr. Caton’s advice to “shock” patients—or, as the residents said among themselves, to “buzz” them. Bruce Harrison, one of the residents, remembers the first time he carried out that advice: “I had no idea how to go about it, where to put the electrodes or how much current to use. Another resident told me the electrodes go on like headphones and that the amount of current doesn’t matter; I should just keep moving up the setting until the patient convulses. The third time I pressed the button the woman’s arms flew up as if she were grabbing for the electrodes. That was the convulsion. She woke up with a grin and asked if it was over.”
The new law permits shock therapy under some circumstances, but Dr. Caton found its working hopelessly ambiguous and stopped recommending shock therapy altogether. One of his ex-colleagues sued the state, claiming that the law interfered with patients’ right to treatment. A nurse who worked with the ex-colleague says she expected such a suit. “The only time he came to the hospital was the three mornings a week he lined up a dozen patients to buzz. I protested that he was buzzing schizophrenics, retardates—everyone—and I lost my job.”
Warning potential victims of murder was a stickier matter. The only scientific help Dr. Caton could glean from the journals was one article stating that youths who set fires, torture animals, and wet their beds are likely to be personally violent ten or 20 years later.
Bruce Harrison (the resident) once presented to Dr. Caton a heroin addict who had seen a friend shoot the addict’s wife to death in an argument over a color television. The addict, drowsy on methadone, promised revenge on the killer and spent his time on the ward fitfully reviewing newspaper accounts of the incident.
Harrison quoted William Burroughs during the conference: “If an addict says he’s going to kill you and pulls a gun then and there, you can believe him. If he says he’s going to kill you tomorrow, you’re completely safe, for tomorrow is an entirely new world to the addict.” Dr. Caton dismissed Burroughs’s opinion as lacking in controlled studies, but reached the same conclusion when the addict couldn’t formulate a consistent plan.
On Dr. Caton’s homeground, the VA hospital, his greatest debates are with Dr. Ostrovsky, the chief analyst. During conferences, when Dr. Caton is ferreting out the seven cardinal signs and symptoms of depression. Dr. Ostrovsky is commiserating with the patient over the early loss of his mother and jumping on references to “milk” and “bottles.” Their disagreements came to a head when Dr. Ostrovsky was hosting Dr. Weidrich, an analyst notable for his work on homosexuality and, moreover, an analyst from New York, the analytic center Dr. Ostrovsky has never quite forgiven himself for leaving. To insure a large audience for Dr. Weidrich, Dr. Ostrovsky sent reminders three times to the residents.
The case was that of a young man from the Los Angeles “S and M” scene who had recently made a suicide attempt. Dr. Weidrich zeroed in on an incident at age five, when the young man’s father left for a few months.
“At the airport, did your father give you a kiss?” Dr. Weidrich asked.
“I don’t think so.”
“Did he at least shake your hand?”
“I don’t remember, he probably did.”
“Did he give you a present?”
“Yes, a kite.”
“A kite, huh?”
Based on this incident, Dr. Weidrich introduced his pet theory that it’s not their mothers that homosexuals dislike but their fathers. Dr. Ostrovsky was smiling. Dr. Caton was restive, holding his white-sleeved arm in the air like a fifth grader who knows the capital of Brazil.
When called on, he ticked off the seven signs of depression (early morning awakening, weight loss, and others) the patient showed and then inquired of Dr. Weidrich, “Are you familiar with the paper by Dr. So-and-so that showed an equal incidence of depressive symptoms among homosexuals and heterosexuals?”
“Dr. Caton,” the analyst replied, “if this doctor did not find illness among homosexuals he just did not look hard enough. Never in my 20 years of practice have I found a healthy homosexual.”
One resident reported that in a crowded elevator after the conference Dr. Caton characterized the visiting professor’s ideas as “sheer bullshit.” Dr. Weidrich went on to the national convention of psychiatrists two months later to protest the exclusion of homosexuality from the official list of diseases.
Dr. Ostrovsky advocates analysis not only for most patients but also for the residents, of whom he is in direct charge. Bruce Harrison, for instance, found himself in trouble once because of his casual dress, “which reflected an unprofessional attitude,” according to Dr. Ostrovsky. Harrison had the imprudence to be wearing jeans when he was called on the carpet in Dr. Ostrovsky’s office.
“Look at you,” Dr. Ostrovsky said, in a restrained shout.
“I grew up in California," Harrison apologized. “I’ve always dressed this way.”
“Your casual student days are over; you’re in a professional program now, a professional program, in fact, that many residents chose over Yale.”
Harrison failed to understand the comparison. “I’ll try to do better,” he said.
“On your own, you probably won’t do any better. What you need is analysis.” By the end of the first year, seven of the 15 residents were in analysis, including the three who were later named chief residents for the next year. Evidently, those who are not for analysis are clearly against it.
Harvey Melnick, who threw in his lot with the drug school, is miffed. “The residents undergoing analysis are so smug. One of them told me at a party that unless I went into analysis I couldn’t hope to understand psychiatry. It was bad enough to be talking shop when everyone else was drunkenly singing.”
Melnick fondly remembers the early first-year parties, when there was more democratic yelping. The high football players sometimes attended. Party-goers sat in circles and massaged the persons in front of them, and amyl nitrate was offered around in a hospital flask. “I went into psychiatry,” Melnick says, “because it was unstraight, but I’m finding that in its own way it’s as earnest and all-diverting as high finance.” Melnick plans to quit and work emergency rooms, a plan typical of dropout doctors.
David Miller and Bruce Harrison are going to stay, having found their niches in the hierarchy. Miller, who has for one year followed Dr. Banville’s advice to analyze the teenage patient who denied her own parents, has become an enthusiastic analysand himself. He now says that his criticism of Banville as a lab fanatic and a Machiavelli was unwarranted—he was actually reacting against his own father.
Like most of his fellow analysands, Miller takes to invoking his analyst often: “My analyst would say I’m being obsessive,” or “That’s the same brand of cigarettes my analyst smokes.” He forewent a trip to Europe to pay for his first year of analysis.
Not either entering the “old boy” system, as Miller did, or quitting, as Melnick is planning to do, Bruce Harrison has been stranded in the middle. He briefly aligned himself with the only faculty member outside the two camps, a behaviorist, who in his introductory lecture used “a faculty position” and “a higher salary” as examples of rewards and the grade “F” as an example of a punishment.
Now, however, Harrison’s behaviorism is even less classical. About himself he says, “I’m just trying to get through this goddamn program. I want to have a nice house and a leisurely life-style; psych pays pretty well and I won’t have to work evenings.”
The residents who have embraced analysis, then, are most at home in the program. The department isn’t big enough for both the analysts and the psych pharmacologists. Dr. Caton is leaving and it appears only Dr. Banville could bridge the two schools.
During their brief ascendance, however, the drug people put some interesting marks on the face of Freud. They invented ways to invade the mind in search of a diagnosis as an internist invades the body with biopsies and catheters, most notably by means of the Ritalin interview, which flushes latent schizophrenia out of the mental brush.
Ritalin is a drug similar to amphetamines. The drug people claim that a quiet schizophrenic will go crazy under Ritalin, revealing his delusions, and that a normal will merely become hyper. A young science fiction buff who let it drop on entering the ward that he had set fire to his last two roommates was a case in point.
He was Bruce Harrison’s patient. “The guy,” Harrison says, “was either a run-of-the-mill criminal or one of the truest science fiction freaks that exist. I administered the Ritalin to him and after a few preliminary ‘my heart is racing’ comments, identified me as Thor and asked for further instructions regarding Earthlings. To us on the ward he had seemed pretty sane, pretty controlled, except for his comments about his ex-roommates.”
Going beyond Ritalin interviews, Dr. Banville once stated in his drugs phase that “with the right combination of drugs, you can have any conceivable personality.” His comment has been widely used as ammunition against the analysts, and even David Miller, the analysand, has become persuaded that no matter what a patient believes is the cause of his depression—a divorce, a dying dog, the bill collectors—three weeks of antidepressant drugs will change his philosophy, such that he hardly considers the original cause.
Drug psychiatrists, in striving to say only scientific things, have ended up making very few statements. They treat depression of any sort with one of four drugs, which differ only in dosage and colorfulness of brand name. The longest discussions they have are on whether antidepressants raise or lower dopamine levels in the brain.
The analysts have ended up talking a lot, perhaps because of long office hours muttering “uh-huh” and clearing their throats significantly. They interpret books, movies, hippies, football players, presidential politics, nose jobs, and yawning.
“Psychoanalysis strikes many residents as a great opportunity to grow a beard and comment on everything,” Harvey Melnick says. “What these residents forget is that a psychiatrist must be a medical doctor first. For example, I heard about the case of a diabetic who came in babbling. The analysts sat there rapping about his father’s desertion, having drawn blood for glucose from the arm a bottle of sugar-water was running in. While they rapped, the guy was vegetable zing. The next morning it was discovered that the guy had taken too much insulin and that his brain had been running all night on a blood sugar of about three.”
“Harvey,” David Miller says, “never negotiated the first quarter’s depression of the psych residencies, when talking to patients forces you to introspect and recognize the craziness in yourself. As a result, he defends against crazy people, keeping them at a distance by doing mechanical repairs on them, and never listening to their problems.”
The subject of the year’s last conference was a fellow who put departmental debates in perspective. He had to come to San Diego all the way from Arkansas, where he was a riverboat worker on speed, living on bread and sugar from restaurant bowls—all at the behest of imaginary voices that had in fact been directing the last seven years of his life.
The fellow was most troublesome on the ward, refusing his medicines and looking puzzled when Bruce Harrison tried to elicit his underlying sadness.
The conference was a running argument in which the riverboater’s final appeal was always to the voices: “They warned me about thorazine; it turns lions into lambs.”
“Why do you listen to these damn voices?’ Harrison asked him in exasperation.
“Why drive,” the riverboater said, “when you’ve got a chauffeur?”
The next day he chauffeured himself out of the hospital through the ventilator pipes.