by Frederick Guggenheim, M.D.
Do you remember your first patient in your chosen specialty, or what was to be your chosen specialty? My first such patient, new to a psychiatric diagnosis, was Eleanor. I was a Clinical Associate internist at National Institute of Mental Health at NIH, having finished three years of Internal Medicine residency. The year was 1965, and I was the On-Call physician for psychiatric emergencies every two weeks at the NIH Clinical Center, even though I had had no specific psychiatric training. I had, after all during my training years at Bellevue Hospital, pretty much seen “just about everything.”
Eleanor, referred to National Cancer Institute at NIH from a small town in California, was 22. When I first saw her, I noted that she was a blond, blue-eyed young woman with a round face, dressed in a hospital gown and lying on her back inside a formidable, clear plastic, oblong, plastic bubble — a so-called Life Island. I had never seen such an isolation device before: it was then on the cutting edge of American medicine, as was bone marrow suppression and transplantation.
The Life Island covered the entirety of Eleanor’s hospital bed. Talking was easy enough. But because of the drug-induced immunosuppression used to treat her acute leukemia, the only way that staff could give her medication, or food, was through two side-by-side, plastic-encased portals that gloved hands or sterilized food samples could be quickly passed in.
The psychiatric consultation for Eleanor was called in at just after the 8:00 p.m. close of visiting hours. Eleanor was upset, psychotically so. Her paranoia and shrieking were spreading histrionically. The precipitating event had been the visitation from a never-before-seen preacher from upstate Pennsylvania. He had traveled to the NIH Clinical Center specifically to see Eleanor. Somehow, he had heard that she was an identical twin being treated for acute leukemia who also happened to have congenital heart disease, while her healthy twin had neither condition.
The preacher was described as a tall, bearded man dressed all in black and wearing a broad-brimmed black hat. He felt impelled to see her — to tell her that she must have acquired these disorders because, somehow, she had displeased God. This freaked Eleanor out. She began yelling and screaming.
Enter, minutes later, me, in the unfamiliar role as the psychiatric consultant. It was very clear that I was having to work far above my pay grade. It was nighttime, and all my psychiatric solons had long gone home. A small dose of oral Thorazine settled down the room, to my relief. After close to half an hour, Eleanor and I finally were able to talk, commiserate, unwind, and get past our introductions.
Following this emergency meeting came months of daily semi-scheduled conversations. She did the talking, and I the listening. Eleanor’s twin, after the initial bone marrow donation, had since returned to California. Eleanor stated that she wanted to go back home, and preferably not in a plain wooden box. Fortunately, she didn’t want to bolt out of the Life Island, which she felt kept her safe, after a series of bone marrow suppressions.
Eleanor was a help to me in my learning to be a psychotherapist. As my first case of supportive psychotherapy, she wanted to talk and she related warmly. We quickly developed a therapeutic alliance. I helped her deal with her emotional distress by being a constant person during a time when her NCI Clinical Associates kept rotating in and out of her life. Mostly what I did was just listen attentively and sympathetically. Psychoactive medications did help. My role as her therapist was to focus on her issues, her voice, and her needs while not raising issues that she was not grappling with. Her mood improved and she became realistically hopeful about her potential for meaningful gains.
Eleanor did talk about her twin, but not about how she was the unlucky one to have several disorders. She accepted what had been dealt her in a very mature way. We never heard anything more from that malevolent preacher. Eleanor did achieve a temporary remission at NIH. She was pleased to achieve her main goal — to fly back home in a temporary remission.
Our work together was good for me, too. Having enjoyed the process with Eleanor, I decided to apply for yet another residency, this one in psychiatry. After all, what was wrong with adding a sixth, seventh and eighth year to my training if I felt it was meaningful!
Frederick Guggenheim, M.D., is Professor Emeritus in the Department of Psychiatry, College of Medicine.