Сэмуэль Шэм - Mount Misery

Friday at five was A.K.'s deadline to come forward. At noon on Friday Solini and Hannah and I sat together in the front row of the newly renamed Mutual of Life Theater, in the Farben. We were attending Misery grand rounds, where the topic was "How to Manage Your Risk as a Psychiatrist." Despite our having heard nothing from A.K., we were flying high: Henry and Hannah were just about done with Misery forever. I, despite the specter of two more years of training, now felt that I had finally come closer to understanding what I'd come to psychiatry from medicine to understand: how to be with people, including patients. The past few weeks working with my patients, I'd felt able to use all that I'd learned during the year.

While our speaking out and taking small actions over the past few weeks may have had some effect, it turned out that Mount Misery was also being rocked by larger explosions in the culture. Things at the hospital were getting more and more chaotic. The algorithms, the decision trees, the boxes adangle from other boxes were banging into each other, coming to rest at weird angles. Just as doctors were no match for businessmen, the hospital was no match for the insurance industry. The industry now more or less owned the hospital, and thus owned the patients too. Talk was no match for drugs. The industry would not be paying for talking any longer. You could almost see the class split in America widening: those who could pay, could talk to a therapist; everybody else would be handed a drug. Most psychiatrists would be pill-pushers. It would be great for the drug industry and the insurance industry. They would be making a lot of money. In some ways, they were becoming indistinguishable, drugs from insurance, insurance from hospitals. Soon, as in publishing and entertainment, it would all be owned by the mammoth multinationals. Risk, once taken by insurance-in fact, risk had been the very reason for insurance, starting with the Medicis-would now be taken only by patients and doctors.

Psychiatry had succumbed to the medical model: diseases, diagnosis, and drugs. Errol was in, Malik out. The shrinks had fallen prey to the very thing they were supposed to heal in their patients: the isolation of one human being from another, and the violence of one human being toward another. What made people sick in the first place was being replicated in the

institutions set up to heal them, all these Miserys of the world. In this, allegedly one of the most human specialties in all of medicine, human beings often seemed to matter least. Perhaps it was inevitable, I thought, sitting there in the almost two-hundred-year-old auditorium, given the original concept of the Yankee founders, that diseases of the mind are a kind of flip side of diseases of the body. I now saw how a lot of the world experts in Misery acted as if they truly believed there was a medical treatment for the suffering of the soul.

And if, already, some of the millions of schoolkids and adults labeled with ADD-Attention Deficit Disorder-and, put on drugs such as Ritalin, were starting to develop a Tourette-like syndrome, with facial tics and twitches that might be irreversible? Well, it's the price we pay, isn't it, for drugging ourselves to attention, for living better chemically? And if, with the two billion prescriptions for Prozac written during my year in Misery, some of the Prozacians had seen their sex drive wither? Well, wouldn't a bit less sex drive be better for society, as a whole, in the end? And if, as is always the case when you throw something as gross as a drug into something as delicate as a brain, you lessen the human part? Well, maybe we've all had enough of this so-called human part, no?

All year long, whenever my common sense had come up against the received wisdom of Misery, the phrase that had come to mind was: "They must be joking." Today's grand rounds was no exception. Mount Misery had decided to address the hot issue of "Therapist Risk" head-on. At the front of the refurbished old auditorium, on a small toylike stage spread under that beautifully proportioned, long and gradual arc you see on doorways and windows and roofs of Shaker dwellings, sat Dr. Arnold Bozer, Dr. Schlomo Dove, Dr. Blair Heiler, and another man I'd never seen before, all in power suits. Schlomo looked neat and clean, his curly hair full of snappy energy, as if it had been permed.

Dr. Bozer presented the case for discussion, in his words, "a DSM 300.14, Dissociative Disorder, Multiple Personality, a young woman who I had had in therapy on Emerson." With a haughty sarcasm that I knew he had copied from Blair Heiler, Arnie said, "Sometimes she would be Sharon Stone, other times Hillary Clinton, sometimes Bambi's girlfriend

Faline, up to a grand total of seventeen multiples. The Sharon Stone multiple claimed that her therapist, me, was abusing her sexually. I have a policy of never touching a patient. I swear I never touched her. Soon thereafter her inpatient insurance ran out and she was discharged to Candlewood, clutching a man's shoe. She still tries to call me sometimes. Gosh, it's embarrassing. She was discharged on Prozac, Ritalin, Placedon and Zephyrill, and nystatin, for her athlete's foot." He sat down.

A tall, handsome, thin man with straight blond hair styled like Bill Clinton's stood up. He was wearing a fine suit and a tie with an insignia with no ducks rampant. This was Dr. Bobby Lee. Shpitzer, a Texan who was a world expert on

Therapist Risk.

"There's a lot of schtupping going on out there," he said. A lot of people laughed. "Lights out, please?"

He proceeded to give a slide show with a commentary that was so witty that soon much of the audience was laughing, as if we were watching Seinfeld. At one point he put up a slide of a famous James Thurber cartoon, of a male doctor leering over the headboard of a hospital bed at a female patient. Dr. Shpitzer read the caption out loud: " 'You're not my patient,

you're my meat.'"

Roars of laughter. Solini grasped my right knee, Hannah my left. I grasped theirs. We all squeezed, hard.

The slide show ended. Dr. Shpitzer then made a heartfelt statement that patient-psychiatrist physical contact was absolutely off limits. Touching the patient, but for a handshake, was off limits. A hug was totally out of bounds. Yet what was the psychiatrist to do when a female patient, maybe a borderline or dissociative or multiple, suddenly got up out of her chair and approached, intent on hugging him? Dr. Shpitzer asked Dr. Dove to demonstrate. Schlomo, ever the showman, popped to his feet.

First Shpitzer said he would show us all what not to do, and told Schlomo to go ahead. Playing the woman patient, Schlomo started toward Shpitzer, arms forward. Shpitzer crouched in a martial-arts stance and with a scream-"Hyahh!" — karate-chopped Schlomo's hands down. Roars of laughter from the audience, horror in Henry's and Hannah's faces, squeezes of knees.

Next the world expert showed us the correct response.

Again Schlomo danced toward him for a hug. Shpitzer grabbed both wrists, crossed them over each other firmly, pushed them down toward the zone between breasts and genitalia, and said, "No, no. This is not therapy."

Schlomo got up on his tippy-toes and danced coyly. "Please, Doctor, just one little hug?"

Roars of laughter.

"No, no. This is not therapy."

"But you're so cute, Shpitzy! Pretty please? One eentsy-weentsy?"

"No, no. This is not therapy. If you persist, I will terminate." They stopped. The audience applauded. Schlomo took a grand low bow.

The discussion then centered on variants of this technique. Dr. Shpitzer passed out his brochure, describing his video course-"Six Quick Steps to Avoid the Pitfalls of Risk"- which we could all buy for $399.95. This would allow us to pass our risk-management requirements for state relicensure as shrinks in the comfort and privacy of our very own homes.