Bipolar Expeditions (17 page)

In this East Coast organization, manic depression appeared to be inimical to the particular kind of order required of bureaucratic organizations. Bureaucratic order, as Max Weber observed, is quintessentially rational: “Bureaucracy has a ‘rational' character: rules, means, ends, and matter-of-factness dominate its bearing.”
⁹
DMDA and DRADA have taken up different aspects of the rationality thrown into question by the diagnosis of manic depression. DMDA wants to show that manicdepressive people are competent and can run a bureaucratic organization rationally, in classic Weberian terms. DRADA prefers to let professional managers run the organization and ensure a greater chance that manic-depressive people will have input into and benefit from scientific research.

Situations where people labeled “irrational” perform “rationally” throw into light both the arbitrariness of the categories rational and irrational and the fuzziness of the line between them. A skeptic could reply that people living under the description of manic depression simply move back and forth from lucidity to confusion, but in doing so they do not disturb the line between the categories rational and irrational. An event from my fieldwork, in which members of a manic depression support group in California were asked by a doctor to vouchsafe passage to a schizophrenic man, illustrates acutely that their position does disturb the line between the categories rational and irrational.

The group met in the early evening, in a classroom provided by a hospital on the coast. The meeting had begun some time ago when Sam, a man I had been told by other members was really appropriately diagnosed as schizophrenic, not manic depressive, came in. From earlier meetings, I knew that he inevitably disturbed the group's routine and that the facilitator had tried unsuccessfully to get him to attend a NAMI group, which is oriented more toward schizophrenia. As Sam came in and sat down, we could all see he had a significant cut on his head. He was mopping up the blood with handfuls of tissues. He told us he had wrecked his van; in fact he had totaled it by hitting a ceiling beam in the garage and his head had then broken the windshield. He showed us his letter to the president in Washington, and began to describe his plans to deliver it in person, but a nurse and an orderly with a wheelchair burst in to take him to the emergency room. A while later the nurse returned to ask someone from the group to go speak to Dr. Torrance in the emergency room in order to “assess” Sam.

Five of us, Erica, Larry, Michelle, John, and I, went down to the emergency room to find Sam. Dr. Torrance came out to the waiting room with Sam, and stood with us in a circle. Dr. Torrance was very young, in his late twenties, earnest in manner, and dressed in green scrubs. He said to Sam, “Can we talk openly? Is there anything I shouldn't mention? Is it all right to talk freely, just like on the fourth floor [the psychiatric ward]?” Sam assented. Dr. Torrance told us Sam's head was fine, there was no problem from his injury: “I am only concerned because I want to feel good about releasing him into a safe situation. We have had a good talk, he's obviously highly intelligent, but you may know he just got out of the hospital yesterday, and I am concerned about him being on a cross-country trip on a presidential mission right now. Maybe a night with his brother until he can get on his feet and get the car fixed, but that means getting him to Mission Viejo.” Erica said she had her car and could give him a ride there. “The brother,” Dr. Torrance went on, “says Sam can stay there, but reluctantly, since he just got him off on his own and this will start up the whole cycle again.” Dr. Torrance then went silent and looked around at all of us with wide eyes. I imagined him realizing that he had just asked a group of people from a manic depression support group to help him assess the status of and take responsibility for a schizophrenic person. He then asked us repeatedly if he could trust us to take care of Sam, to look after him well, and be sure Sam got to his brother's house.

All of us were now caught in a kind of double bind: if we were crazy, we couldn't assess and care for Sam, but if we were not then maybe Sam wasn't either. Not knowing what else to do, we all, including Dr. Torrance, trooped off to the garage to assess the damage from the accident. The car was an old VW van with a homemade camper built into the body. The van was once painted red but there was no shine left, and the dented aluminum panels of the ancient camper were all askew.

The accident had broken the windshield on the driver's side and bashed in the passenger side roof. Apparently the vehicle was too high for the roof beams of the garage. The support group discussed how best to get Sam to his brother's house, going over where to leave the van, how to map the route, and whether Erica was the best person to drive him. Erica, now the chosen driver, asked Sam repeatedly if he had what he needed for the night—things like his toothbrush, a jacket, and so forth. At this, Sam went in and out of the camper several times, each time struggling with a door that would neither open nor close readily, but never seemed to find his overnight supplies. Finally he emerged from the camper grinning, carrying a large fruit basket full of fresh oranges, which he explained he had picked at an orchard earlier in the day. With a quirky smile, he enthusiastically offered the oranges around. Amid our laughter and disbelief at this nonsequitur, Sam said, pointing to his van's bumper, “Look at my sign, my sister got it for me.” The sign was a bumper sticker that read, “If you haven't changed your mind lately, maybe you don't have one.”

The dizzying switches in this small event kept us all off balance. How would anyone decide who exactly was capable of being in charge here? The doctor, after all, was handing over responsibility for Sam to a bunch of manic depressives. The manic depressives, for their part, understood what Sam needed but, no strangers to rapidly shifting states of mind, were still having trouble keeping up with Sam's U-turns. There seemed to be no way out because we were all caught in a contradiction: if each of us had to be either rational or irrational with no space in between, clearly the doctor would be the only rational person. The rest of us would be irrational. But then the doctor's decision to hand Sam over to manic depressives would clearly be irrational! Worse, the manicdepressive group's behavior was practical and goal directed, hence apparently rational, even though the group members' diagnoses made them irrational by definition. Of course, one way out of this paradox is to imagine that the manic depressives were all perfectly managed by their medications, and their medications in turn perfectly managed by their doctors. The doctor could be assumed to be perfectly rational without the aid of any medications. That would leave Sam, probably unmedicated, as the only one out of control. Framing this situation in terms of a hierarchy of management—doctors control the drugs, drugs control the patients—allows us to escape the paradox, but at a cost. Such a framing would leave out the cultural heart of the matter, the complexities that make Sam's situation compelling and interesting. What Sam, Whybrow, Nemeroff, DMDA, and DRADA show us is that psychiatrists, patient advocates, and people living under the description of manic depression constantly (like anyone else) move back and forth across the arbitrary line between the rational and the irrational.

CHAPTER FOUR

 

I Now Pronounce You Manic Depressive

Kissing the picture of a loved one. This is obviously
not
based on a belief that it will have a definite effect on the object which the picture represents. It aims at some satisfaction and it achieves it. Or rather, it does not
aim
at anything; we act in this way and then feel satisfied. The description [Darstellung] of a wish is,
eo ipso,
the description of its fulfillment.

—Ludwig Wittgenstein,
Remarks on Frazer's
Golden Bough

H
ow do people adapt their sense of themselves as persons when they receive the diagnosis of manic depression? Although the form of DSM-IV categories—the orderly, nested, numerically coded organization we saw on display in the teaching video—would seem to speak for their unambiguousness and clarity, in practice they are anything but. Nor do psychiatrists who have the authority to apply these terms to other people always find the process straightforward. What the terms mean, how they should be applied, and even whether doctor or patient will get to apply them are all matters of contention.
¹
In this chapter, we will see the creativity that patients and physicians bring to how DSM terms are used. The issues play out differently in the various medical contexts of my fieldwork in Baltimore, in the pseudonymous Wellingtown Hospital. Wellingtown is a large teaching hospital, and audiences for weekly Affective Disorder Clinical Rounds are largely made up of physicians and medical students. The patients have all been admitted as inpatients on one ward or another. Rounds serve a teaching function not only for medical students, interns, and residents learning as apprentices how diagnoses are made, but also for more senior physicians refining their knowledge. A senior physician chooses cases for rounds that will illustrate some aspect of a condition particularly clearly: for example, whether a patient has major depression or bipolar disorder; or whether a patient is experiencing hallucinations or not. Even with the guidance of the medical resident who presents the patient's medical history and the careful interviewing done by a senior physician, each case produces a welter of complex events and experiences. The goal of rounds is didactic: to produce at least small islands of clarity out of the complexity of a patient's life, so that in practice a psychiatrist can decide on the diagnosis that will allow the most appropriate treatment.

My purpose in describing these rounds is to illustrate the inventive interactions between physicians and patients in what has been called a “contact zone,” a space where people with different kinds of power and perspectives negotiate cultural meanings.
²
Because the perspective I take in this chapter is limited to rounds as specific events, what I am able to say cannot represent the full depth and quality of understanding that psychiatrists, nurses, and other medical staff bring to bear on diagnosis and teaching. Others, such as the anthropologist T. M. Luhrmann, have described the poignant dilemmas faced by psychiatrists determined to help patients empathically, especially when they are hampered by the constraints of managed care.
³

The events I witnessed in rounds evoked for me the term “groundsea,” an archaic West Indian name for a “swell of the ocean, which occurs in calm weather and without obvious cause, breaking on the shore in heavy roaring billows.”
⁴
A distant storm, out of sight, is often the cause of a ground-sea. In the academic context of rounds, the sober and calm demeanor of both faculty and students and the staid presence of the imperturbable DSM-IV make for the appearance of calm weather. But as the following cases show, distant storms are indeed sending heavy, roaring waves to break on this shore. As we will be able to see by the end of the chapter, the distant storm in question arises from social distinctions in the wider society—based on race and class—that bring disquiet into the medical setting. The disquiet is the distant storm whose force we will finally glimpse. The cases that follow are either from psychiatry grand rounds, in which a patient and his or her case are discussed formally before a large audience in an auditorium, or from Affective Disorders Clinical Rounds, the more informal weekly teaching sessions in a small classroom described in
chapter 2
. The eight cases I describe (two sessions of grand rounds, six sessions of clinical rounds) are arranged loosely in order of their complexity, and accordingly I will have the most to say about the last case.

(1) I'm in a Hole

In this grand rounds, a young doctor, a resident, began by reviewing the patient's medical history. Called “presenting the case,” this narration followed a standard form (abbreviated here), which students learn to follow in medical school.
⁵

This is a forty-six-year-old white, divorced woman with a two-year history of depression, who has recently been suicidal. Her father was treated here, too, and he urged her to come. She has a military family background and has moved frequently. Her father was depressed and her mother was alcoholic. [Here he described in some detail the many jobs she has had.] She had thirteen years of psychotherapy with no drugs, then after that took many drugs, including Zoloft, Klonopin, Restoril, and Xanax: she was so doped, she had to quit her job. She became suicidal and took to drinking to lessen her pain. She had restrained herself from committing suicide because of the pain it would cause her father and sister, but drinking lessened this concern. She searched the Internet for suicide methods, including some from Kevorkian.

At Wellingtown Hospital, her therapist diagnosed her as bipolar because of her rapid speech and high energy level: she said her nerve endings were alive, she felt high as a kite, and her mind was going a thousand miles an hour. Her ex-husband said she was babbling. Her therapist changed her meds to Depakote and Prozac, then to Depakote, Serzone, and Nortriptyline. At present, she is stable.

After this description, a senior physician, Dr. Murray, took over the session as the patient herself, introduced as Ms. Peterson, was escorted in from a side door. She was seated in one of two armchairs on the stage, side by side, facing the audience, but angled slightly toward each other. Dr. Murray interviewed her, by turns sympathetically and probingly. He thanked her sincerely for coming. Most of his questions focused on her experience of being depressed, as in this brief excerpt.

Dr. Murray:
You have been depressed for so long, and you've been through so much, it must seem a long haul. I am glad you have been good, you've followed your doctor's advice, and you seem still willing to try. When you are depressed, what is different?