September 19, 1996
Dr. Bill Bennett
Columbia Medical Center
Apologies for the long delay. I'm not a great correspondent I suppose. But I've been completely involved in my practice with hardly a moment to do anything not work related. It's the same old story...
My patients are a varied and interesting lot. I almost yearn for the simpler clinic days when any advice that involved more than an hour's consultation was sent elsewhere. This therapy stuff is hard.
I have three crisis right now and I'm in a quandary over all of them. I've got a patient, Joseph, aged 33. He's a sociopath who has been arrested for physically abusing his wife. I believe he has also abused his two children, although he has never admitted to it. He has an extremely variable temper, liable to flare-ups where he loses control. He also is fond of firearms. I prescribed Prozac to Joseph and I was having some good results--he felt less pissed off at people is how he described it. But Joseph decided to stop taking those drugs in favor of anabolic steroids. As a result, he had a complete psychotic break, beat his wife and ended up in jail. His wife threw him out and got a protective order. He quit the steroids, only to start abusing some central nervous system stimulant (I'd guess Crystal Meth.) He is foaming about how his wife screwed him and about how the government can't get between a man and his wife and apparently threatening violence upon his wife. And he comes in this week and accuses me of screwing his wife. I calmed him down over that, but she seems to have left town with the kids--one could hardly blame her. And he keeps making threats against her, me, his employers and the world in general. Of course I've told him that he can't abuse these drugs, but if he comes next week as high as he did this week, I don't know what to do. Should I have him committed as an imminent danger to others?
Then I have a patient Sylvia, aged 38. I told you about Sylvia in a previous letter. She's the one who's husband had a vasectomy and she experienced an increased interest in sex after taking Zoloft. We talk about her using sexual relations as a way of punishing her husband, but it doesn't stop. She's having four affairs a week. The Zoloft has released her sexual appetite and I can't switch her off the drug. She says that there is a side effect, sure, but it is a desired side effect--this is what she wants now in her life. I'm getting angry phone calls from Tom and I'm worried myself, but Sylvia insists. Actually, Sylvia's insistence is more than just continuing a desired lifestyle. There's an urgency to it that I didn't understand. Her marriage is clearly over, as far as Sylvia is concerned, but she's making no moves to resolve the situation one way or the other. I question her about it and she says that she just wants to leave things like they are for now.
I get a report from SII that someone has broken into the computer and extracted confidential health records from the personnel files. And Sylvia, who's too smart and careful not to be practicing safe sex, isn't. Sylvia finally confesses that she has rifled through the records to come up with men who, because of their negative HIV status, are on her eligible list. She even slept with one of my other patients who's married and is now suffering from anxiety least his wife discover his indiscretion, but that's another story.
Oh, and Sylvia's living with this very attractive woman who has made it very apparent that she would welcome my attentions--I can't imagine that the Ethics Board would sanction that kind of involvement.
So Sylvia comes in for one session and announces that she's pregnant. It had all been a scheme to get herself pregnant with an acceptable, although unknowledgable, donor while still married to Tom. In California, apparently, if the child is conceived during the marriage the husband is responsible for child support even if he can prove that it isn't his. It looks like Sylvia is going for an acrimonious divorce and was looking for an extra fillip to exact further revenge. I was impressed by how coldly calculated it was. Actually, Sylvia and Tom are a good match in that regard.
Then I realized: Sylvia had gotten pregnant while taking Zoloft. I hadn't warned her of the dangers! Her husband had a vasectomy and, although I knew she was having affairs, I had ascribed them to a revenge motive and not to a desire to get pregnant. Anyway, I screwed up. But it was early in the pregnancy, so I felt that any problem would likely result in a miscarriage rather than a developmental abnormality.
Sylvia goes off to the obstetrician and, the next thing I know, I get a call from her friend at the hospital. Sylvia has an abnormal ultrasound and possible twins. I rush over to the hospital and Sylvia has been sedated by the resident--she's been beside herself. The upshot is that the Zoloft probably wasn't a problem, but Sylvia irregular menses and age might be. Her twins are of different gestational ages. Apparently, she ovulated while pregnant and, given her varied sexual activity, there's a good possibility that her twins are by different fathers. How's that for a letter to Lancet? Or maybe the National Enquirer! Now Sylvia wants my advice as to how to break the news to her family and to Tom.
Then there's Helen. How do I give you the true picture of Helen? Clinically, she's a highly paranoid, highly delusional, persecutory schizophrenic with auditory hallucinations. But she's a lot more than that. This is a woman with a tremendous intellect who's drowning in a sea of delusions. She has layer upon layer of complexity. You can't help me on her psychological condition because she has disappeared. She had a vision where her son had committed a murder and she has gone to be with him, somewhere. She may have left the country. I don't know what to do until she contacts me.
And I have another patient, Cassandra. She's a nice girl who has been ill since she was fifteen, but never properly diagnosed. I send her to a good internist here and he finds she has Chronic Fatigue Syndrome. I've been reading up on it, and there is no cure, no treatment, and there is a social stigma attached to the disease--everyone accuses the patients of malingering. She's clearly not, but even to make a diagnosis, you have to rule out mental health factors--it's a negative diagnosis. When everything else is ruled out, then you can say that a patient has CFS. So she's now trying to come to grips with having a chronic debilitating illness. I feel a huge amount of compassion, but it's like counseling someone after they find out they are terminally ill--well, perhaps not as severe as that, but you get the picture.
Let's see--there's Sarah. She's only come in once so far, but she is feeling like she's lost control of her life after having a heart attack at 33 years old. Everyone is walking on egg shells around her and, she is experiencing a strong upsurge of hypochondriasis on top of it all.
I have a new patient named Phylis. Phylis is unbelievable looking, like a supermodel but more sophisticated and interesting. Well, Phylis has a hobby--she likes to dress up like a frump with theatrical make-up and old clothes and then hang around in sleazy bars--she calls them dives. She can't tell her husband about her obsession--and it is an obsession, she's willing to jeopardize her good marriage to continue it--so she is lying about her whereabouts to cover it up. Her web of deceit is so complex now that she's having trouble keeping it straight, and that's where I come in. She wants me to teach her some memory tricks to keep it all straight! Likely. Oh and her alter ego, Martha, actually came to a session. She has an elaborate fixed story to aid Phylis on pulling it off without being caught in an inconsistency.
And listen to this one! Every Wednesday morning like clockwork I come into the office and am greeted with this weird fax. They are all different, all images constructed with the computer somehow. I've gotten nine of them so far. I can't tell whether it is an elaborate practical joke or a desperate plea for help. All but one have not been personalized in any way, however and the one that was personalized was done so in a way which suggested that it was an afterthought--not with the same graphic quality as the rest. So I think I am just one recipient among many for this fax. But they are so strange--populated with tortured male figures and serene female ones. The tortured male figures are actually being physically molested--an I-beam runs through one, for example, while the most recent has the guy transforming into a giant horny lizard of some kind. Very strange and quite artistic in a surreal and grotesque kind of way.
I've decided to come clean--I have another problem. I have a patient named Anna with whom I'm infatuated. I can't wait for her appointments and I find myself having a series of extremely inappropriate fantasies and dreams regarding her. Of course I'm not acting on these unprofessional impulses, but the issue of a psychiatrist becoming sexual involved with a patient is no longer just a theoretical curiosity to me. I understand the impulse even if I'm not likely to act upon it.
So how are they treating you? Did they cut your department's budget like they were threatening? And how about Burger? Is he still wielding his riding crop?
Okay, the latest from surfing the Internet:
Two therapists are walking down the street. A strange man jumps out of the bushes, punches one of the therapists in the nose, and runs away. The bloodied therapist continues walking as if nothing had happened.
Very truly yours,
Charles Balis, M.D.