Personal Accounts: Sanity, Psychosis, and September 11, 2001

When working with patients with chronic mental illness, we learn to measure the world by a different set of standards. What is important to the world at large is often inconsequential to them. Priorities of rent, paying bills, and getting to work on time are often replaced by concerns about the next level of privilege walks, cigarettes, and cups of coffee. There is solipsism to psychosis, and this is fully evident on a unit of long-term psychiatric inpatients. They share the same space, the same suffering, and the same frustrations but are too drawn into themselves and their own delusions to see those facts.

I was in charge of such a unit on September 11, 2001. I remember the way the sky looked so deceptively blue, clear, and calm. From my vantage point on the Jersey side of the Hudson River, I saw the sun reflecting brightly off the Empire State Building and the Twin Towers, a sight I had seen hundreds of times before, having traveled the surrounding highways while commuting daily to college and medical school. I could not have imagined how very gray those skies would soon become. I was not scheduled to be at the hospital that day. But as the surreal events of that morning began to unfold, unraveling all reason and reality, my own plans changed. In futility and helplessness, I reported to the hospital, to respond to the need for all hands on deck. People would be flocking in, needing help. It was my duty to be ready and waiting.

When I arrived at the hospital, nothing was as it should have been. Patients and staff alike were huddled around every available television screen, staring with wonder, disbelief, and horror. I entered the clinic just in time to see the first tower fall. It was a visceral sensation, like something within me was disintegrating along with the building. If the planes hitting the buildings had seemed unimaginable, the implosion of the towers was beyond comprehension. The clinic patients sat in silence, a silence shared by the attending psychiatrists, residents, and clerical staff.

I raced to my unit, concerned now for my patients. I am not entirely sure what I expected to find. Most of the time, the patients had very little interest in each other, let alone the outside world. Attempts at current events groups, which entailed giving sections of the daily newspaper to patients and asking them to each report on one item of interest, usually were more likely to stimulate discussions of the luncheon specials at some local restaurant than whatever was in the headlines. A cluster of patients sitting together in the television room or in the large common area did not necessarily signify any meaningful interaction between them, unless the experience of breathing each other's air can be considered in this light. So, when I came upon the television room filled to capacity with both staff and patients, I was not at first sure of the impact, if any, of the news that played on every channel. There was general silence, as there had been in the clinic. The staff looked horrified. The patients' reactions were harder to read. Most watched the screen intently for a few minutes before shuffling out to check the time; terrorist attacks should have no impact on a scheduled privilege walk, after all. No point in denying their receptors of nicotine or caffeine just because civilization was crumbling around them.

But one patient in particular drew my attention. "Peter" was a bright, highly educated but extremely ill man. Living with schizophrenia for more than a decade, he had already been robbed of his career potential and was extremely isolated. The cognitive decline was profound. Where there should have been the brilliant, inspired ideas of an educated professional, there were, instead, cluttered, incomplete thoughts and incessant voices whispering half-truths and misperceptions. His lack of insight into his illness was striking. He came from a family with significant genetic predisposition for mental illness. His sister also had schizophrenia. Unlike Peter, however, she recognized her illness and embraced treatment, finding relief in clozapine. Indeed, she had been able to live independently and maintain meaningful employment as long as she remained on her medication. Peter clung desperately to the belief that he was not ill. His years of refusal to take clozapine seemed to confirm the denial. He would take any other medication offered, even though he did not agree that he needed it, but accepting this one drug would mean he had given in to the enemy. It would mean he, like his sister, was ill.

Peter was intently watching the television screen. While he paid attention to the images of destruction, it was clear that he was also still dealing with the internal stimuli that plagued him relentlessly. I wondered how these inputs were meshing or clashing in his brain. How was he reconciling the two? How was he processing all this? How were any of us?

I watched from behind the nurses' station, the additional distance from the television screen providing me with some increased sense of safety. There was, in truth, nowhere to hide. I saw Peter get up from his chair. He was one of the last to leave the room, but I imagined that he had finally hit his limit. I was surprised when, instead of wandering off to his room as usual, Peter came up to the desk. He stood in front of me, making minimal eye contact, his body rigid, unnaturally erect. Pushing his glasses up on the bridge of his nose with an air of authority, he said, "I want to give blood."

I was completely taken aback. Nothing before had broken through the walls of psychosis that had built up around him. Yet now, in a time of national crisis, Peter had risen to the occasion. Somewhere, deep within him, there still dwelled some connection to the rest of humanity. He had seen the devastation, and with whatever he could, in whatever way he was able, he wanted to help. Stunned, I thanked him and told him we would let him know how relief efforts were being coordinated.

Like the rest of us, Peter waited for the call that never came. As the hours passed, we quickly realized there would be no overflow of patients rushed to us from across the Hudson in need of first aid and treatment for injuries. Those of us who stood vigil at our lonely posts slowly came to the realization that the only mission that would be undertaken in the days to come would be one of recovery. As the solidarity of the crisis and despair faded, we all slipped slowly back into our routines. All of our usual, mundane concerns of September 10, 2001, now seemed as important as our patients' focus on cigarettes and coffee and in comparison with the world-shattering events of the day that followed. Peter, too, slipped back into his solitary world, detached from reality. But for once, perhaps, that was the sanest route to take.