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In the Locked Ward

Throw away your Sigmund Freud, Mrs. Neugeboren…because I am going to cure your son!” It is 1968 and Dr. Cott is offering massive doses of vitamins B-6, B-12 and C. One of the first of a score of psychiatrists to take charge of the schizophrenic Robert Neugeboren, whose story is told in these two books, Cott’s confidence is, alas, unwarranted. Still, the same could be said of most of those who follow him, each with his own favorite wonder cure, whether it be electroshock, insulin, Adapin, Mellaril, lithium, Stelazine, or any number of others. When one doctor announces with great excitement that he is going to try the “brand-new” anti-convulsant Depakote, Robert’s brother Jay, who is telling the story, has to remind him that actually Robert has already been on Depakote. He responded briefly, then relapsed.

Jay, however, is ever willing to hope, and in the early Nineties, when a psychiatrist decides that Klonopin is the way forward, the author welcomes the decision. Only a little later he discovers that this is the same drug that has just been prescribed to their eighty-two-year-old mother who suffers from Alzheimer’s. Is it likely, then, that this will prove the promised “magic bullet” for schizophrenia?

Meantime Robert is frequently deprived of his phone privileges. Why, Jay complains, “what possible medical reason can there be…for depriving him of any contact with the world beyond the ward?” Invariably he is told that “the staff like Robert” but that he can be “impossible” and even “dangerous.” “He curses loudly, screams at telephone operators, keeps demanding refunds from the phone company,…spits at aides, scratches them, strikes other patients.” Reading Imagining Robert and Transforming Madness, it soon becomes apparent that dealing with the schizophrenic from day to day is far more of a problem than the choice of his new medication.

A novelist by profession, Jay Neugeboren is a constant thorn in the flesh of those who have treated his brother over almost forty years of mental illness. It is not that he has an axe to grind. On the contrary, he displays an exemplary openness to a wide range of points of view. No, Jay’s behavior is irksome first because he just will not leave things be. He continues to visit his brother, even when those visits leave Robert more agitated than they found him, and he always insists on knowing what medication is being offered, what therapy proposed.

Stop being so concerned about your brother,” advises Dr. Laqueur, a great advocate of coma-shock therapy (this back in the early Sixties). “You should get on with your own life.” From time to time, as the years go by, the dashed hopes, the violent crises, readers of these books may be inclined to agree with Laqueur. Yet at the same time they would have to acknowledge the author’s constantly implied objection: “But how can my ‘own’ life be separated from my brother’s? They are inextricable.”

For the other quality of Neugeboren’s that psychiatrists find so unsettling is his memory. Not only does he recall every wonder drug and improbable therapy that has been tried on his brother, but he also remembers how his brother was before his illness and the dramatic family scenario in which the two of them came to consciousness. This is the story he tells in Imagining Robert, and we cannot come away from it without reflecting that narrative and contemporary psychiatry are implacable enemies. With all its mess, waywardness, and ambiguity, the well-documented, convincing narrative reminds readers of everything they intuitively know beyond psychiatry’s austere vocation for separating things out into demonstrable facts and repeatable results.

The book begins with a crisis. Invited to attend his nephew’s high school graduation ceremony, the fifty-year-old Robert (schizophrenic since twenty) disappears, stays out all night, returns distraught and belligerent, and two days later has to be forcibly hospitalized. The author then goes back half a century to give us the childhood of the Neugeboren brothers and proceeds by switching back and forth from past to present throughout. The method is dense with implication. Though the author never insists on links between now and then, it is clear that he finds it hard to uncouple his brother’s mental illness from the more general madness he experienced in the family as a child. Is this a failing, or merely common sense?

Born in 1938, Jay is five years older than Robert. The parents are Brooklyn Jewish. Relatives are legion, likewise arguments. In thrall to a shared vision of the happy family, Mother and Father are nevertheless in permanent conflict. Mother is strong, generous, impulsive, insatiable; Father whining, intelligent, incompetent. Infallibly, his businesses fail. Jay must remove debtors’ letters from the mailbox before Mother sees them. Does she know he is in league with Father? “This [Robert] is my love child,” she declares cruelly. “That one…,” she points to Jay, “who could ever love that one?”

A hospital nurse, Mother works night shifts to pay the bills, but also finds time to be involved in charities. She is greatly admired in the community, bitter and irritable at home. “What can I do to make Momma happy?” Father asks. “You’re a bright boy, Jay…. Please tell me what to do.” The man is desperate. He goes down on his knees before the whole family, crawling across the floor to lick his wife’s shoes. “That’s how much I love her.” But why does she insist on coming to the dinner table topless, fondling her breasts with her free hand? Why does she parade around naked? Jay watches enraged as Mother paints little Robert’s nails red, his mouth pink. Jay can’t play on the baseball team because that would dishonor the Sabbath. Jay must not date a goy! It will kill Mother if Jay dates a goy.

Crushed by his wife’s imperious hysteria, the father nevertheless refuses to get a steady job. Anything to please, but not that. So there is always something for her to demand that won’t be granted. The tension is extraordinary. She is wronged, wild. The arguments escalate. Confused but compos mentis, Jay gives up trying to win his mother’s love and starts to detach himself. He’s an adolescent now. More amenable, darling Robert is entrusted with the task of keeping his parents together. “Shall I divorce your father?” Mother asks. “No, you mustn’t!” Robert learns to play the clown, to do music hall acts. He performs in public. What has he spent his life doing if not watching one splendid performance after another? When he puts on a show everybody laughs, everybody claps their hands. The Neugeborens are a happy family with a charismatic child. It’s exhausting.

In short, here is a group of people who thrive on what has come to be called in the mental health profession an excess of “expressed emotion.” Indeed interested readers may find it instructive to turn for a moment to Julian Leff and Christine Vaughn’s book Expressed Emotion in Families,1 where they can observe a research team ticking off boxes on interview sheets to establish the number of times the relatives of schizophrenics speak critically of each other, or make direct eye contact, or use coercive imperatives. Although a psychologist of the systemic school, which originally developed out of Gregory Bateson’s ideas,2 Leff is one of those who accept that schizophrenia is basically an organic disease, but nevertheless notes that the sufferers’ families of origin tend to be characterized by high levels of confrontation and conflict, something that may trigger a crisis. In this scenario the therapist’s role is thus to seek first to measure, then reduce that level of negative engagement by teaching relatives to avoid excessive eye contact, verbal criticism, and the like. Of one young woman who had a psychotic crisis only days after returning from the hospital to live with her mother, he remarks that the decision to spend the weekend on the family’s small cabin boat was fatal. Think of the constancy of eye contact in the cramped cabin of a boat!

The subtext of Leff and Vaughan’s book is optimistic: this side of the schizophrenia problem is quantifiable and hence, we immediately assume, manageable. It can be tackled in an organized fashion if teams of researchers and social workers are sent out who will train families to deal with their loved ones. But Imagining Robert reminds us that this is no ordinary form of stress whose reduction we can sensibly plan for. Here every expression of emotion is generated within the inexorable dynamic of the parents’ relationship, which is also the crucible in which two young personalities are now being formed. Past decisions have determined present dilemmas. Entrenched positions have been assumed. Above all the emotions expressed frequently reveal contradictory states of mind. “How make sense of what made no sense?” Neugeboren wonders, reflecting on the way declarations of love came simultaneously with gestures of cruelty. What behavior can one learn in such an environment?

Shortly after Jay manages to leave home—against his mother’s will—Robert begins to buckle. His schoolwork becomes erratic. He leaves home, declares he is homosexual, lives with an assortment of dropouts, does drugs. Then comes home again. Then leaves again. Intriguingly it is the mother who first suggests he go to a mental hospital. What but mental illness could explain her darling’s sexual inclinations? Perversely eager to see what the inside of such an institution is like, Robert confides to his brother that he faked a test to be admitted. Jay insists he take another. Now the doctors say Robert’s fine. No problem at all. Shortly afterward he has his first psychotic breakdown. “You and Mother put me here,” he tells Jay from his hospital bed in a locked ward.

While I am not surprised,” Neugeboren remarks, halfway through the second of these two books, “that mental health professionals disagree strongly with one another, I am startled, occasionally, by the virulence with which they attack each other.” Having completed Imagining Robert with the powerful story of his brother’s slow decline into chronic illness, Transforming Madness poses the question: regardless of the etiology of schizophrenia, what if a new drug were to return Robert, and others like him, to a stable state of mind? How can such people resume “normal life” when their identities are now so entwined around their illnesses, when, in particular, they have never formed an adult personality?

Inevitably, as Neugeboren travels the US looking at a variety of different rehabilitation programs, this question brings him up against a heated controversy: Therapy versus drugs, which matters most? And this in turn, like it or not, cannot but reflect back on the problem of the etiology of the illness (organic, relationship-based, or both) and indeed on our whole sense of what it is to have a self, to be a person.

One anecdote will suffice to sug-gest the complexity of the issue. In 1997, fifty-four now, Robert is given the new wonder-drug Clozaril. Albeit marooned in the locked ward of the Bronx Psychiatric Center, he has, mainly thanks to brother Jay, a new doctor and a new social worker. There is dedication and excitement. Fifty percent of patients respond to Clozaril, one of a new generation of more carefully aimed and milder dopamine blockers. Some months into the treatment, the doctors remark “that Robert is making ‘slow and steady’ gains—he is learning to control his rages, he is interacting more easily with others, he is not starting fights, he is being ‘realistic’ and ‘appropriate’ about most things.” Neugeboren himself notes that his brother seems to have overcome his “total self-absorption” and is now sharing food, cigarettes, and money with others in the ward and showing interest in their health.

Encouraged by this progress, Robert’s social worker concentrates on preparing him for the move to the open ward and relative freedom. Everything seems set for at least partial recovery. But two weeks before that crucial move is due, the social worker is abruptly transferred. Despite continuing with Clozaril, Robert rapidly deteriorates. He now refuses to consider moving to the open ward and becomes manic and enraged, particularly with his brother. When Jay phones, he shouts, “You put me here, so you get me out of here, you goddamned son of a bitch cocksucking bastard!” and hangs up on him. Even when not enraged, Robert’s talk degenerates into streams of childlike associations. “When I visit him,” Neugeboren writes, “and bring him the food he has requested, he refuses to eat it. ‘You eat it Jay,’ he yells, ‘I don’t want it. You eat it. Mother made it. Can’t you tell? Mother made it.”’

Questions: If the drug works, why does it appear to stop working on the departure of the social worker? Was it partly the atmosphere of “the great attempt” that brought about Robert’s improvement? Might that explain the drug’s only 50 percent success rate? Or is the brain learning to rewire itself around the transmitters that the drug blocks? Then, is the departure of the social worker the real cause of the relapse, or is this rather an excuse for Robert to avoid going to the open ward and a freedom he is afraid of? Does Robert want to demonstrate to his brother Jay, of whose authorial success he is openly jealous, that no amount of fraternal string-pulling will save him, from either the vagaries of the institutions, or his own self-destructive impulses? He is his own man. “This is my home, Jay,” Robert insists, referring to the closed ward with its harsh regulations and frightening inmates. “Why should I go anywhere else?”

To return to Neugeboren’s surprise at the vitriolic exchanges between mental health professionals, the quarrel he is chiefly referring to is, of course, that between those who support exclusively organic approaches to schizophrenia and those who would like at least to include reflections on family dynamics and other environmental factors. Curiously, the development over the last twenty years of the theory of neural plasticity would seem to have eliminated the need for this head-on (to risk a pun) collision. This is the idea, now supported by a large body of research, that while the brain is indeed conditioned by genetic factors, it also responds and changes according to environment and experience, the latter often being crucial in the triggering and even transformation of particular genes.

In a recent paper delivered in Venice, Glen Gabbard, Callaway Distinguished Professor at the Menninger Clinic, speaks of experiments indicating how psychotherapy can be shown to have altered both the chemistry and gene expression of the brain. Referring to work by Steve Hyman, director of the National Institute of Mental Health, Gabbard goes on to suggest that gene-environment interactions give rise to a sort of “hall of mirrors” in which it is far from easy to analyze the reciprocal reflections. He looks forward to the day when an awareness of the brain’s plasticity—its tendency to change in response to experience—might finally erode the “reductionism” that has divided the mental health world into two hostile camps, the psychosocial and the neuroscientific.3

Yet the conflict continues as bitterly as ever. The disagreements are so heated, one suspects—and it is the great merit of Neugeboren’s books that they prompt the reader to ponder the matter at length and with plenty of material to chew over—because at the deepest level the introduction of a nonorganic element into a consideration of the etiology of schizophrenia and other mental illnesses threatens to undermine the very basis on which the advocate of the exclusively organic approach operates.

Why is this so?

Neugeboren quotes Leston Havens, Professor of Psychiatry at Harvard, as remarking that despite their reputation for vanity, many mental health professionals, and medical students in particular, fail to recognize their own importance. They “come and go among patients as if their knowledge and skills were all that counted, their persons not at all.” The remark is pertinent, for it points to the underlying vision that drives the profession. The medical students are not looking for personal engagement with the patient. They don’t really want their “person” to make a difference. That is not the “importance” they are after. Rather they want to learn (why not?) to heal the patient with a precise and controlled intervention, the exact dosage of the exact drug chosen after an exact diagnosis based on meticulous and exact analyses of spinal fluids and brain scans. They are in thrall, that is, to the great and creditable dream of Western medicine, a dream most powerfully represented in the image of the perfect surgical incision made in sterile conditions by the absolutely steady hand. It’s an idea that never fails to stir our imaginations. Not for nothing did we arrive at the aberration of lobotomy.

But to make the perfect incision one must be operating from an absolutely stable vantage point. By suggesting that the self, patient’s and doctor’s, is constantly both product and producer of a group dynamic (family, workplace, society, nation) and never (even with all its chemistry in place) an objective given (for in this scenario the group dynamic will influence the organic brain)—to imply, that is, that in the long run a patient may respond as much to a “good morning” as to a drug, or alternatively that a doctor’s judgment may be affected by a schizophrenic’s antagonistic behavior—is to shift the ground from under the feet of those who would heal the self with a perfect intervention from a detached position without.

Again and again in Neugeboren’s account of his brother’s vicissitudes one senses the importance of the element of taste. Quite simply, Robert’s psychiatrists retreat (and understandably!) from what would be the very bad taste of becoming involved in the patient’s messy life. They don’t want to know about the ugly incidents that took place some months or years or days before a psychotic crisis. They don’t want to decipher the patient’s incoherent obscenities or know how often he masturbates. A lower-paid social worker can be given the unpleasant task of sympathizing and encouraging the patient to “behave.” Meanwhile, in the gleaming laboratory of the collective imagination, through years of tasteful dedication (and massive financial investment), a cure is being prepared. The magnificent gesture of the decisive intervention is at hand.

  1. 1

    Julian Leff and Christine Vaughn, Expressed Emotion in Families: Its Significance for Mental Illness (Guilford, 1985).

  2. 2

    See my article on Bateson and systems theory, “Unlocking the Mind’s Manacles,” The New York Review, October 7, 1999.

  3. 3

    The Ungrateful Patient,” paper delivered at the Congress for Psychodynamic Psychiatry, Venice, Italy, April 9, 1999. A revised version entitled “On Gratitude and Gratification” will be published this year in the Journal of the American Psychoanalytic Association.

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