The side effect of persons with psychiatric illness like bipolar disorder going off medication can be destructive. This patient had been in trouble with the local police, who saw her as a troublemaker and a menace.
Be not forgetful to entertain strangers: for thereby some have entertained angels unawares.
The knock on the door came just after 1 in the morning, as my wife and I were getting ready for bed. In the small, Central New York town where we spend summers, “ordinary” people do not knock at that hour, save for the rare tourist with a broken down car and a dead cell phone. Shuffling barefoot into our kitchen, I approached the front door with trepidation and asked, “Who is it?” A young woman’s panicky voice, muffled through the glass, replied, “I’m looking for my brother’s house! Do you know where he lives?” I pulled back the curtain with the door still locked, and saw a sweaty, disheveled figure, standing next to what looked like a child’s scooter. The young woman was stuffed into a short skirt, 2 sizes too small for her zaftig physique. “My car broke down!” she said, her eyes dark with tear-smudged mascara, “I had to ride here on my scooter! Please, can I use your phone?”
I realize now that the bizarre scene at that hour should have prompted more caution on my part. Wisdom would have dictated keeping a safe distance from this late-night intruder. But my gut told me here was a young woman in distress, and my religious beliefs-whispering from somewhere deep in my subconscious-must also have been working within me. After all, doesn’t the Bible (Genesis 18) tell us that Abraham and Sarah welcomed 3 strangers into their tent, bringing them food and kindness? For all they knew, the strangers were thieves or murderers!
In the Jewish faith, hospitality toward strangers is a mitzvah-a commandment. On the other hand, my 30 years of psychiatric training should have had a stronger voice in the matter. Individuals with psychiatric illnesses are not, for the most part, given to violence. In fact, they are more often the target of violent attacks-especially persons with serious mental illness who are also homeless. Yet untreated psychosis, especially when accompanied by substance abuse, is associated with an increased risk of violence. No doubt, I should have been more wary of someone who had just ridden a child’s scooter to my house, at 1 in the morning.
Sighing deeply, I said, “Okay, you can use my phone.” I opened the door and let the young woman into my house.
At first, things went reasonably well. She gave me a number to call-presumably, her brother’s-but there was no answer. The young woman was sweating profusely and became increasingly more agitated. I thought I smelled alcohol on her breath, but her state of mind suggested a more complex set of problems. “I was just in the hospital,” she blurted, “and my heart stopped! They had to revive me twice. I’m bleeding internally! I have ovarian cysts. I know I’m supposed to take my medication but I don’t like the side effects-and besides, I like my natural highs! Can I have some water or some juice? My blood sugar is low . . .” And on and on her narrative went, in what emergency department physicians and psychiatrists usually describe as “talking ragtime.” If you are not actually in a florid manic state, it’s almost impossible to mimic the “flight of ideas” that this phase of bipolar disorder provokes-a kind of staccato, rat-a-tat-tat of loosely connected thoughts, often delivered in a loud, insistent manner. Okay, I thought, I have just let a floridly manic patient into my house. My wife-a retired psychiatric social worker-had wisely scurried upstairs, to the relative safety of our bedroom.
Over the course of the next 20 minutes or so, I did my best to calm down our young visitor, but there really is no calming down a manic patient, short of medication and a quiet, dimly lit room. And yet, something curious happened to me as I listened to this distressed young woman regale me, at breakneck speed, with her tales of woe: I began to feel less fearful. And I began to see that beneath the sweating, speeding, mascara-smeared mess of her acute illness, a decent human being longed for a more stable life. I offered her a glass of fruit juice, and she gratefully drank it.
Her name was Kara. She lived in the poorer section of town, and-at age 18-had been in and out of psychiatric hospitals for several years. She knew she needed help, but she never stayed on her medications: “Too many side effects!” But the side effect of her going off medication was the ruination of her life, and the enmity of others. Kara had been in trouble with the local police, who saw her as a troublemaker and a menace-which was not entirely inaccurate.
I later learned that the same night as her visitation, Kara had gone to the firehouse and claimed that someone had placed a bomb in her grandmother’s house. This led to an expensive wild goose chase by our town’s tiny police force and volunteer firemen, diverting them from a major brushfire. I suspect Kara had not acted maliciously and that the false report was the product of her delusions. Still, her actions did not endear her to the local authorities. To make matters worse, she was known to run around with kids who had “been into bath salts,” the latest supercharged hallucinatory mix. It later occurred to me that Kara’s manic symptoms and behavior might have been due, in part, to this nasty chemical brew.
“It sounds to me like you could use some medical help, Kara,” I said at last. “I’m going to call 911.” She did not protest. In fact, she said, “Yeah, I could use a doctor.” Within a few minutes, 2 police officers and a fireman showed up at our door, followed shortly by an ambulance. The fireman argued a bit with the police, urging the young policewoman in charge to “have that girl arrested!” I felt obligated to interject something vaguely professional, and said, “Officer, this young woman really needs medical attention, not jail.” The officer agreed. Within a few minutes, Kara walked peacefully out of our house and was taken to a nearby hospital for evaluation.
Kara’s intrusion into my home life left me reflecting on how so many individuals with serious psychiatric disorders are ill-served in this country. Many lack health care insurance. Many patients with so-called dual diagnoses (major psychiatric illness plus substance abuse) lack access to comprehensive care. The very small minority of patients who represent a danger to themselves or others, but who refuse treatment, often have few alternatives to involuntary hospitalization-only a few states have so-called outpatient commitment laws, which can often lead to successful (albeit involuntary) treatment. Finally, given the broad, unmonitored discretion of police officers in such cases, Kara might well have wound up in jail.
I don’t believe I’ll allow any more late night visitors into our home. But I am not quite prepared to say that letting Kara in was entirely a mistake. Oh, yes-about those 3 visitors Abraham and Sarah entertained: one biblical interpretation suggests that they were heavenly messengers.
Acknowledgment-My thanks to James L. Knoll IV, MD, for his helpful comments on this piece.