A psychiatrist and their patient reflect on treatment.
“Here comes Jimmy Hendrix” were the words I recalled Keith saying as the anesthesia was administered before his electroconvulsive therapy (ECT) treatments.
Keith Cunniffe, a 19-year-old college freshman referred for treatment of depression, first walked into my office on April 24, 1987. Mr Cunniffe, a 46-year-old married father of 2 working as a social work clinician, administrator, and teacher, walked out of that office for the last time on December 30, 2014; I was retiring. Memories of our work together returned when I read his generous review of my memoir, Rearview: A Psychiatrist Reflects on Practice and Advocacy In a Time of Healthcare System Change. In it, he identified himself by name and referenced the chapters on ECT and partings, each of which included anonymized material from his history. Having had no contact with any of my patients since retiring, I called to thank him.
During that conversation, Mr Cunniffe explained that he was trying to be more disclosing about his personal story. In that context, we decided to collaboratively tell the hopeful story of his recovery.
What follows is the true story of a youth becoming a man due to perseverance in the face of a frightening clinical descent and of an extended psychiatrist-patient partnership which witnessed hard won ascent. It involved struggle against what at times seemed an intractable mental illness and against a health insurance industry which threw up obstacles to treatment.
How It Began
Cunniffe: I started college at Fordham University in the fall of 1986 looking forward to making new friends and, hopefully, having a girlfriend. I vividly recall early on walking past Keating Hall, the pastoral campus’s centerpiece, and thinking that I felt a kind of darkness that I had never felt before. I wondered, “Is it really possible for a person to feel this terrible?” It was. I sensed that this dark curse would be my companion for years to come, which turned out to be correct. That walk on that day marked the beginning of my descent into mood swings, depression, emotional upheaval which would last for years, and, briefly, into psychosis.
When I walked into Dr Perlman’s office the following April, I was looking for a quick fix to relieve my hellfire. I wanted medications. He agreed they were indicated. I also appreciated his interest in me as a person. That turned out to be critical to the therapeutic bond which connected us and proved decisive in my healing. That it would become a 27-year passage through psychological hell into healing was unimaginable.
Early Contacts: Our Differing Memories
Cunniffe: I have little recall of my early meetings with Dr Perlman. I know that I sought care at Fordham’s Counseling Center but have no recollection of my counselor nor of being on an antidepressant. During the early phase of my treatment, many trials of psychiatric medications were initiated and abandoned. Phototherapy, first implemented in October 1987, would prove beneficial thereafter in supporting my mood during the darker months.
Never an impulsive person, I recall an episode in my early 20s when I obsessed about getting my hair shaved off. I frenetically ran to a barbershop, hopped into the chair, and gave the order. I must have seemed unbalanced as the barber asked several times if I was sure before complying. During that period, I strongly felt tension in, and energy moving quickly through, my body. Extended periods of depression were punctuated by brief bursts of hypomania. How I managed to hold a job and graduate with my class in the face of such dramatic instability seems unfathomable. Most individuals consider their college years as among their best; for me, they were the worst years of my life. Even now, I am saddened knowing that I can never get them back.
Perlman: Keith presented as an attractive, smart young man who described his low moods as seeming to fluctuate with the weather—a bit more alive on brighter days and more lethargic on darker days. He described feelings of indecisiveness, emptiness, and disenchantment. His sleep was “out of whack,” he had lost 25 lbs, and his grades were well below the excellent average he maintained in high school. He explained that he had friends but avoided intimacy. He harbored obsessive thoughts of harming others and himself, though he had never acted upon them. Despite all this, he continued to attend college and work a part time job. Before being referred to me, Keith had seen a college counselor and been started on an antidepressant by his family physician.
Descending and Beginning the Ascent
Cunniffe: My descent into psychosis was terrifying. Having experienced mood swings for years, I additionally started to experience psychotic symptoms, certain that my life was over. Delusionally, I believed the devil was controlling my thoughts and behaviors. My second hospitalization in September 1990 was harrowing. During that extended stay, I had suicidal and homicidal thoughts. After admission, I remember being unable to move upon awakening. Why I was restrained in a strait jacket remains uncertain. After beginning another course of ECT, I began to feel decidedly better. My mood stabilized and I was relieved that the psychosis abated, never to return. Thankfully, I never harmed anyone.
All of my psychiatric hospitalizations but 1 were at St. Joseph’s Medical Center where Dr Perlman was the Director of Psychiatry. The psychiatric unit was not what I expected. I had thought of such places as ones where patients continuously display acute symptoms, fight with each other, and are restrained. Compared with what I imagined, being there felt benign. Restraint was rare, patients conversed with each other, and most of the staff were genuinely caring. I appreciated that my primary nurse on most admissions refused to give up on me. Ironically, I encountered her years later when I was a social worker on a community-based mental health team. Although I felt tense at first, we handled our meeting professionally.
At some point, I became aware that Dr Perlman had considered dropping me from his care which evoked feelings of anxiety and hurt. I was glad he had not, as we still had work to do together and had good chemistry. I do not know why a particular patient and psychiatrist have good chemistry, but we did. As both a patient and therapist, I have learned that chemistry cannot be manufactured. It is either there or it is not.
Perlman: During the early months of our work, I had no intimation that Keith’s would be an unusual case, one that would bind us together for the almost 3 decades. What follows is a synopsis of an extensive, complex case history.
Trials of psychotropic medications from several classes either failed or were not tolerated. Phototherapy for a seasonal affective disorder proved beneficial and has been utilized since. We met regularly for therapy. Themes emerged related to sexuality, gender, family expectations, interpersonal relations centered on power, grandiose aspirations, faith, and uncertain memories of abuse, among others; these, in various transformations, remained central to Keith’s therapy.
Failure to stabilize Keith clinically resulted in his first inpatient psychiatric admission in November 1988. It followed shortly after an emergency department visit precipitated by increased drinking, out of control behavior, and rapidly fluctuating mood. Subsequently, acknowledging that his father was a heavy drinker, Keith fully abstained from alcohol. Despite ongoing instability, Keith graduated from college with his class and remained employed. Later admissions were marked by intermittent psychotic phenomena, such as thoughts of being controlled by the devil, distortions of body perception, and by fear of losing control. He underwent his first ECT treatments during an admission shortly after his graduation. He was discharged on psychiatric medications, attended a psychiatric day treatment program, and continued to see me. Again failure! During the next psychiatric admission, he was transferred to a longer term psychiatric facility where he received additional ECT. Personally exhausted by work with Keith—all of my patients had my personal phone number and the calls I received from Keith and his family at all hours were numerous—I considered not accepting him back into my care at discharge from the extended stay hospital. Ultimately, I discarded that idea, intuiting that he should not be given up on. I recall firmly disabusing Keith, a psychology major, that his diagnosis was not schizophrenia. Keith’s last admission and ECT were during the spring of 1992. Improvement seemed feasible. In all, Keith had 7 psychiatric admissions and received 49 ECT treatments.
Turning the Tide
Cunniffe: Many decisions were vital to my recovery. Among the most important and anxiety laden was the giant step of moving from my parent’s home to a supervised residence, which they supported. My sense of independence grew. I enjoyed social work school. At my first placement, a psychiatrist allowed me to observe ECT. He explained that general anesthesia and a muscle relaxant were given before the electric current was applied. As I watched a patient receive ECT, I noticed that his limbs barely moved and the treatment was over quickly. What I saw jibed with my lack of recall of my ECT.
Lasting cognitive effects from ECT are rare and I am cognitively intact after receiving many. Despite prejudice against it, I know it helped me and probably saved my life. It is likely that I am one of few individuals to have both received and witnessed ECT.
My gains allowed me to grieve my father’s passing and that of others without eliciting mood swings. Sensing that psychotherapy, which was very helpful, had limits in relation to my spiritual yearnings, I sought spiritual counseling. I hoped that attention to my spiritual needs might contribute to my healing. It did afford a sense of having an intimate conversation about God and, perhaps, of approaching a mystical experience. I highly valued the opportunity to explore spiritual issues with advisors who shared my religious beliefs.
Jobs after graduation had me working with geriatric clients and individuals with serious mental illness. In what has proved a successful professional life, promotions followed and I am currently the Chief of Social Work at a psychiatric VA facility as well a respected adjunct professor of social work at Fordham University.
My illness devastated my ability to relate to others. As an example of my difficulty reading social cues, during the time that I was living alone I often met an attractive, pleasant woman at the bus stop. She tried engaging me in conversation. I spoke about her during therapy, wondering if I might ask her out. After hearing me mull this question, Dr Perlman said, “The only thing more she can do to get your attention would be to hit you on the head with a 2 X 4.” We married in 2003 and have 2 children. Rebuilding friendships too has been challenging and rewarding.
Perlman: After what proved to be his last admission, the tide gradually began to turn. Keith’s attendance at a day treatment program continued but was titrated down. With trepidation, his living arrangements became increasingly independent—first, heroically, moving out of the room he had shared with his brother since childhood, next moving into a supervised living situation, and then into apartments, shared then solo, and finally into housing with his fiancée. Taking no psychotropic medications, he relied on phototherapy during darker months. Despite lurking retrogressive psychological forces, Keith progressed.
Despite my expressed concern that clinical work might be threatening, Keith started social work school in 1994. Clinical rotations confronted him with entirely new challenges. He heard professionals discuss patients with serious mental illness in what he perceived to be a derogatory manner but, not wanting to reveal his personal history, felt constrained about speaking up. He voicelessly empathized while watching ECT being administered. He resented his supervisors’ power, feeling as knowledgeable as they based on his experiences. The ravages of the AIDs epidemic shook him during an elective at the GMHC. One clinical rotation occurred at a facility where he had been treated. Surmounting these trials, he stayed on track, graduating from social work school in 1996. Positions of increasing responsibility followed during which he learned to advocate for himself in the crucible of workplace politics. Today, Mr Cunniffe directs the social work department at a VA psychiatric hospital.
Over time, he rebuilt social skills and gained the strength to deal with loss, weathering well the deaths of his father and 2 spiritual advisors. Keith’s spiritual quest was not explored deeply because it did not interfere with his progress. Finally, after decades of close attachment, he successfully negotiated my retirement. He had become a resilient man despite the omnipresent shadow of his psychiatric history and the frightening possibility of relapse.
Therapy’s Role in Building a Life
Cunniffe: The strange alchemy to the therapeutic relation remains difficult to tease out. Most importantly, I could see it helping. Early on my ability to utilize therapy was limited; I was just trying to keep my head above water. In retrospect, Dr Perlman’s sticking with me was invaluable.
As a child, I fell under a large wave and feared drowning. With therapy, I began to perceive that event as a metaphor for my illness and, incorporating the negative experience, became a tool for healing. For me, having a mood disorder means that the waves never stop and the possibility of psychologically drowning remains. My ability to view important events from different angles suggested that therapy was working.
Being bullied contributed to my illness. Believing the word trauma is overused, I do not use it lightly. But, for me being bullied was traumatic! An older kid terrorized me; he cursed and threated me into doing what he ordered. Once he grabbed and squeezed my testicles painfully. Learning that he was moving afforded me tremendous relief. Bullying became a recurrent theme in therapy. I distinguish between self-esteem and self-confidence. Despite all, I believe myself to be a good person. However, because of bullying, I have always found asserting myself difficult. The synergy of bullying and psychiatric illness delayed my psychosocial development by a decade—an enormous loss!
Perlman: Each epoch of Keith’s recovery saw progress in terms of his autonomy, social skills, and interpersonal relations. These themes alluded to previously were repeatedly addressed in psychotherapy. Thematic obstacles recur across our lives. What differed for Keith was the tenor of their role. During the early years of acute illness they held the potential to trigger relapse; later, as gains were cemented, they came to feel like everyday issues addressed in personal therapy.
A Broken Mental Health Care System
Perlman: My files contain almost as much material related to health insurance as to clinical matters. As Noel, Keith’s father, held a corporate managerial position, they fortunately had ‘good’ mental health coverage. Extracting those benefits required prodigious, unreimbursed work on my part and a sustained effort by Keith’s father. There are reams of preauthorization requests to provide outpatient care, appeals of treatment denials, requests for authorization of inpatient admissions, extensions of stays, to administer ambulatory maintenance ECT, and more. The system seemed designed to impede access especially if treatment was lengthy, costly.
Cunniffe: During my first years of treatment access and cost caused constant worry. I feared it would be too expensive or even unaffordable for my parents if the insurers denied psychiatric visits or stop paying for medications. My father reassured me by saying, “You will get what you need,” to my great relief. In hindsight, I appreciate the effort made by Dr Perlman and my father especially as my father’s effort was conducted quietly, without complaint. My apprehensions waned when I became eligible for Social Security Disability Insurance due to the severity and chronicity of my illness, resulting in my gaining coverage through Medicare and Medicaid. At that point Dr Perlman accepted Medicare. Later, when I was insured through my employer, Dr Perlman and I agreed on a mutually acceptable fee and I received partial reimbursement as an out-of-network benefit.
Dealing With Retirement
Cunniffe: Hearing of Dr Perlman’s retirement elicited great anxiety. I accepted the new reality reminding myself that, during the worst of times, the progress I made would have been unimaginable. What I’d achieved was what I’d hoped for. Six months later, I was shaken but weathered the departure of my next psychiatrist. Today, I see a psychiatrist for medications and a social work therapist. Occasionally, I wonder if a time will come when I will not need psychiatric treatment but do not dwell on that thought because I’m doing well. Success is success!
Perlman: I experienced a mixture of emotions as I anticipated closing of my practice after 40 years. Those feelings were rooted in bringing down the curtain on a foundational aspect of my life. Severing relations with patients whose well-being was important to me would be trying. By the time we parted, Keith had arranged treatment with another psychiatrist.
During our last session, we exchanged thoughtfully inscribed books. At the last moment, Keith requested a hug. I relented, crossing a rarely traversed boundary. I never regretted acting in a human way.
At our leave-taking, my professional satisfaction in what he/we had accomplished was accompanied by a tad of what felt like parental pride. Despite all, I harbored a concern for his future. Months later, learning that his new psychiatrist had departed, my worry grew—so many separations in such a short time! When we reconnected, I was relieved to learn how well he had managed those storms.
Our Closing Thoughts
Today, we confer as adults and clinicians sharing satisfaction in the success of our work. We believe that beyond the early frightening years, our work was an enduring collaboration. We have noted aspects of the mental health care system which impacted treatment and recovery. We understand that what was achieved, although unusual, demonstrates why no one should be considered a ‘throw away person.’ We assert that as neither the clinician nor the person seeking treatment can foresee the outcome of their therapeutic work at its inception, all deserve the best shot possible at symptomatic relief and personal growth.
Solving the complex jigsaw puzzle of treatment is clinically challenging. The current mental health system frequently obstructs the mixing and matching of therapeutic tools rather than facilitating their use. The struggle for improvement in the lives of persons with serious mental illness is inherently difficult and ought not be burdened by obstacles thrown up by the system ostensibly meant to facilitate recovery.
We cannot explain what creates positive therapeutic chemistry but believe that working towards a mutually trusting relation is invaluable. Clinical gains often involve accepting risks and a trusting relation is foundational to taking them. After therapeutic exploration, the ultimate decision on whether to proceed resides with the patient.
Our 27 years of therapeutic collaboration demonstrates that caring for a person with serious mental illness is a long-term proposition requiring tenacity on the part of clinicians and patients. For each the work is demanding and exhausting. The path towards recovery is unpredictable. Setbacks are demoralizing. Outcomes remain uncertain or tenuous. Therefore, there should be no artificial time limits on treatment. Mr Cunniffe’s current utilization of medications and psychotherapy should be viewed as an appropriate, ongoing engagement with treatment.
We write collaboratively to offer our perspectives regarding the process of treatment and recovery. Because serious mental illness afflicts many, our plea is that all afflicted persons deserve an opportunity to achieve their full human potential.
The editorial staff of Psychiatric Times® posed several questions to the authors of, “Hear Comes Jimmy Hendrix.” Dr Perlman’s and Mr Cunniffe’s responses follow.
PT: We hear that, “…most psychiatrists are no longer doing therapy. As therapy seems to have been an important part of Mr Cunniffe’s recovery, what do you suggest?”
Perlman: For me, the joy of practicing psychiatry came from being able integrate psychotherapy and biologic treatments in caring for my patients. Those who, for whatever reason, choose not to do therapy should still value both arms of treatment as being necessary for successful care and closely collaborate with an experienced, trusted therapist.
PT: A hot topic we hear about from our readers has to do with self-disclosure by health care professionals.
Cunniffe: I have contemplated disclosing my psychiatric history for quite some time but chose not to do so fearing it might impede my ability to climb the career ladder. Unfortunately, there are some individuals in our field who might have considered my illness as disqualification for promotion. I now feel that I am at the pinnacle of my career, meaning the issue of upward mobility is no longer a concern.
I have never disclosed my psychiatric history to any of my patients as doing so has never seemed necessary. Perhaps in the future I might consider doing so if I thought it could clearly benefit a particular patient in a unique situation.
Perlman: The difference between our lives likely explains why Mr Cunniffe first writes about the potential career harms which he might have incurred from self-disclosure before addressing the matter in relation to his clinical practice. I can easily imagine patients for whom Mr Cunniffe’s story would be inspiring.
I was not self-disclosing but neither did I hide myself. My office had family pictures, diplomas, books, mementoes, and other items from which patients might deduce information about me. Private patients had my home phone number for decades before cell phones became available. Any member of my family might answer when the phone rang, allowing a window into my life. I do not recall these openings being damaging, although occasionally they led to therapeutic conversations. How much one reveals is determined by one’s type of practice, the professional’s comfort level, and the patient’s need to know, always bearing in mind that too much information may burden and inhibit discussion—there is no simple answer.
Cunniffe: If I have one piece of advice for clinicians it is to listen first and talk second which best allows patients to express what they want to express. Asking too many questions may be experienced by some patients as intrusive and dampen their willingness to share.
Perlman: I believe that the most critical element in working with challenging patients is to “hang in there,” trying an informed variety of psychotherapeutic, psychosocial, psychopharmacologic, and somatic approaches, always holding onto the hope that some combination will affect change. We must not forget that the practice of psychiatry combines art with data driven science.
Dr Perlman is a retired psychiatrist; was the Director of the Department of Psychiatry at Saint Joseph’s Medical Center, Yonkers, NY; he is a past president of the New York State Psychiatric Association and past Chair of the NYS Mental Health Services Council. Mr Cunniffe graduated from Fordham Univeristy and the Hunter Graduate School of Social Work; he is Chief of Social Work at the Montrose VA Medical Center and an adjunct professor of social work at Fordham University.