ELISSA ELY
Diagnosing strengthsI THINK the Diagnostic and Statistical Manual of Psychiatry is all wrong. Traditional diagnoses are about pathology. What if instead they described strengths? What if they identified needs that could then be met?
For instance, a delicate soul who cannot tolerate stimulation might carry a diagnosis of "Should-Have-Been-a-Librarian." The impatient, self-sustaining misanthrope is "Ought-to-Live-in-Minnesota-Each-Winter." The anxious doer is "Needs-to-Be-Rotary-Club-President." These diagnoses are forgiving, not judgmental. They are also specific, because all of us are specific. A former boyfriend once called me, "33-Degree-Bug," meaning "Without-Exactly-the-Right-Temperature-She-Will-Wither." He was annoyingly right. For a 33-Degree Bug, it always seemed a good idea to work in the same place. Now I am leaving the hospital where I have been for 12 years. It is like an autoamputation. The body will survive, but the limb is going to wither. Institutional life will carry on: admissions, discharges, team meetings, chart reviews. Each morning, I know, the polite man with a huge wastebarrel will still hold the ward door open to let staff pass in, the overhead operator will alternate shattering and small announcements: "Code Blue, Dietary Department," then, an hour later, "Hop on Down to the Main Lobby for the Easter Raffle." The patients will still struggle. The nursing staff will march heroically through years that become harder all the time, buoyed by graveyard humor. "I'd love to give you a job," one said once to a patient (whose diagnosis is "Desperately-Needs-to-Feel-Herself-Useful"), "but it's against your human rights." Everything will continue. But knowing this was not personally comforting. As the last day approached, routine remained unbroken. On Friday mornings, the Life Skills Group meets to discuss sleep, nutrition, symptom recognition, understanding feelings, avoiding conflict, and finances. We cycle through the same set of topics over the course of three weeks, then start at the top again. A week earlier we had talked about nutrition. We had gone around the room and everyone had come up with a favorite food. The idea was to find something healthy in their choices. This was challenging. A patient with cholesterol in the 300s (he claims to be an unrecognized archangel and therefore immune to lipid disease) said his favorite meal was steak and hominy grits. Someone else wistfully mentioned lobster. A woman in the corner said she loved Thanksgiving turkey -- the bird, apparently, had to be holiday-specific. This week's topic was supposed to be leisure skills, ridiculous in a locked hospital, where there is too much of every day and at the same time no genuine leisure. Why talk about the pleasures of weight-lifting when there is no gym? Cookie baking without a kitchen? Hiking when the rural grounds around the hospital are off-limits except for two sidewalk paths? Meditation in the midst of endless noise? Some of the patients in the Life Skills Group are on my team. I have known them forever, prescribing for illnesses I secretly doubt I could survive myself. We had talked about feeding the body. Suddenly it occurred to me to ask -- in lieu of leisure skills -- what fed their souls. "Steak and hominy grits," said the archangel. "After they're digested." "It's too heartbreaking to dig up bones," said someone else, by way of refusing to answer. "Confession. Jesus is lonely waiting for us in the Tabernacle," said a woman who got lost between her bedroom and the dining hall. "Mindfulness," said a man, waking out of some daze, speaking one word, then closing his eyes again and refusing to elaborate. "Esteem. It's where you hold your silence and your happiness," said someone else. This was not precisely to topic, but still everyone nodded. It all made sense. Sometime later, I sat across from a patient, someone I have known for years, someone I importantly like to think I have helped. I had just told him I was leaving. He looked shocked and miserable. I was feeling awful for us both and wondering, as I have many times since making the decision, whether I can exist outside of this climate. The hospital has been my better half. Diagnostically speaking, once I leave I'm not sure when I will be myself again. My patient has been in the hospital for many years. But he is no 33-Degree Bug. His diagnosis is different from mine. Over decades, he has survived catastrophe and disillusionment, every form of poverty and discouragement. For a person with the limitations of psychosis, he is phenomenally adaptable. "Well," he said, sadly. He paused. "Well," he said again, in a thoughtful voice now. Then, after another small silence, he asked the only right question. It was true to his diagnosis, "He-Who-Survives-By-Withstanding." "Well, if you're going, could you tell me who's coming next?"
Elissa Ely is a psychiatrist. © Copyright 2004 Globe Newspaper Company.
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