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It wasn't my turn to do rounds in the emergency room that week, but a senior psychiatrist had asked me to fill in one night for him, as a favor. I stopped by our triage desk on my way to the emergency room to find out if there were any potential admissions. The triage officer said that one patient, Katherine Holden, might need to come in to the hospital. I took a deep breath and in a very even tone of voice mentioned that I had gone to college with a Katherine Holden. “Well, this can't be her,” the woman replied. “She's much older than you.” Of course I knew that it had to be her, and that this was the night our paths would cross after so many years.
In our small college, Katherine was one of the stars. She was tall and black, with a resonating voice and a regal bearing. She had come North from a tiny rural town in the deep South. A relative of Katherine's had attended our school before her and had recommended the school to her. Katherine was a natural leader, and we flocked to her and enjoyed her intelligence and charismatic wit. We always thought of her as a “character,” whose creative juices were tinged with a bit of wildness and abandon. She and her friend Mattie taught us white girls how to dance, and we had great times together. Her senior music recital was a tour de force, and it was clear to all of us that she was headed for a great career.
I had seen Katherine only once since then, maybe a few years after graduation. She was quite thin and seemed remote. Someone told me that she spent most of her time in her room. I heard about her once or twice after that. She had gone to graduate school to study music, but didn't last in the program. At some point she had appeared for a visit at Mattie's place in New York and had behaved in extremely odd ways. Mattie came home one day and found her apartment door unlocked. Katherine had gone, but inside, in the middle of the living room, she had left a candle burning on the floor. Surrounding the candle were various objects arranged in concentric circles.
Not knowing what to think, Mattie called Katherine's relatives, the ones who had brought her up North. They weren't too alarmed by the story, according to Mattie's report. They said, with reserve and a fair degree of resignation,“Thank you for calling. If she shows up again, please let us know. We've been trying to get her back into a hospital for a while.”
That was the last I had heard of Katherine. It was about 15 years earlier, which was five years after we had graduated. I went on to become a psychiatrist. When I learned about schizophrenia, I was taught that it affected 1 percent of the population, that we all probably knew someone who suffered from it. I didn't. Except maybe Katherine. Maybe that's what had happened to her.
After my training was completed, I worked for a while on each coast, then wound up in the same small city where Katherine had gone to graduate school long ago. I didn't know that she had remained here to live. It turns out that we circled each other's lives for about six years in this very small city before we met in the psychiatric emergency room that night. She had become a highly disturbed woman, someone whose mental illness had transformed her life into one of poverty, squalor, and psychosis. I had been working and teaching in a place that treats severely mentally ill individuals who are poor. Like particles of matter moving around in a small space, we flew by each other according to random paths of Brownian motion, and then one day we simply bumped into one another.
I walked to the emergency room with trepidation. This wasn't what I had in mind for a reunion. There was also the seed of doubt the triage officer had planted. Maybe this woman wasn't the person I knew. This Katherine Holden was old and in bad physical shape. She had been brought to the hospital by the police at her landlord's request. He had gone to her apartment because of a leak into the apartment below. He found that her place was flooded, and that she was living in unspeakable squalor. She was clearly in need of help, but she fought off her helpers, and she arrived at the emergency room on a stretcher, held down by physical restraints. The resident presented her case to me, because I was the attending psychiatrist, so there I was, hearing “report” on my old friend.
The resident said that Katherine had been given medication and was now sleeping. I told her that I had known Katherine in college, years ago, and I was considering if I should see her. Katherine had been so agitated earlier in the day that we weren't quite sure. Would she feel embarrassed to see me in this context? Would she lash out at me? We didn't discuss the issue of whether I could handle it, but that was on my mind too. In the end, it was not possible to predict whether Katherine would react well or badly. I made my decision based on the fact that an old friend was in the part of the hospital I was responsible for at that moment, and I couldn't imagine just turning my back. So I went in to her room.
Katherine was lying on a cot all twisted up in the sheets. I wondered for a moment if it was, in fact, the same Katherine I had known. Her hair was sticking out in clumps, and her face was bloated. Her eyes were cloudy at first, then brightened considerably. She broke into a huge smile, said my name and then, with great irony, “I can't believe it's you!”
I sat down on the edge of her bed, and we talked and laughed for nearly an hour. She was quite mad, actually. She told me stories about what she had been through that were too fantastic and convoluted to hold more than a few grains of truth. She had me laughing, though. We talked about our mutual friends from the past, and she filled me in on their happenings. Mattie had married a white guy, which is what Katherine suspected she had been trying to do for years. Henry had given up art to become a computer consultant. There were other tidbits that seemed as accurate as the blurbs in the alumni magazine from our old college. We chatted and laughed, and then I left. Neither one of us made reference to the future or to seeing one another again.
I reported to the resident that the visit had gone well, and that she should proceed with plans for admitting Katherine to the hospital. Then I walked out of the emergency room, slowly got into my car, drove toward home, and burst into tears. I'm not even sure what all my emotions were. The questions I asked myself about Katherine were along the lines of how, and why, but the feelings were more like anguish and loss. Katherine was still funny and bright, but so unable to use those talents to serve herself well. Her mind was full of others' plots and schemes against her, and rage toward those who loved her. What had become of Katherine?
For the first time I had an inkling, a taste, of what a family member might experience when a loved one becomes ill in this way. The clinical staff who treated Katherine were respectful and reasonably kind, but they saw her only as a very sick woman. I told them a bit about her past—who she had “been,” or at least how her life had been shaped years ago. “Oh yeah,” they'd reply, in a tone of distant amusement.“She told us that she was once a great singer, who worked with lots of famous people.” They might or might not have believed Katherine, but the past seemed almost irrelevant to her current situation. Now she refused to have contact with her family, refused to take medication, and refused to believe that she might benefit from professional help.
It was a tragedy really, and I knew it. The nurses, doctors, and social workers who cared for her saw the illness, but could they appreciate the tragic dimensions of it? Katherine's old self and new self were so cut off from each other—family members not being allowed to see her now, and treaters not able to know what she had been. For nearly one hour that night in the emergency room, the old and the new parts of her life came together, but I'm not sure either one of us wanted to let that happen again.
Dr. Steiner is associate professor in the department of psychiatry at Yale University School of Medicine, 34 Park Street, New Haven, Connecticut 06519. Jeffrey L. Geller, M.D., M.P.H., is editor of this column.
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