Unexpected countenance of change

SOMEONE, a psychiatrist, discouragingly once said that people don't change very much, but the little ways they change, when they do change, are enormous. It seemed a dour but accurate assessment.

It was practical wisdom -- the kind someone would acquire after being in the business many admirable years. Just recently, a patient proved to me that it is utterly wrong.

The first time we met, she said: ''I don't get along so well with people. When you're temperamental, no pill helps. I've been afflicted with hallucinations and delusion."

I asked what kind.

''You're the doctor," she said sharply. ''You should know."

Life had not gone as expected. She had been an old-school beauty. She still wore linen suits and earrings of a timeless design, meant to top the classic little black dress. Her hair was impeccable, her natural complexion artfully pink. She worried a great deal about her skin. She thought the medication might be causing her to age prematurely. This was not vanity. It is possible that the antipsychotic was causing liver spots, which put the whole treatment in danger.

Part of her illness -- the afterbirth of paranoia -- was a sour rage that could not control itself. It was like a seizure. It spilled onto family and neighbors, and her beauty became unattractive. She was snappy and unreliable, full of fragility that drew you in and bitterness that repelled. She thought the neighborhood children were laughing at her, and, because she acted as if they were, they did.

''There's not much thoughtfulness in the world," she said.

She had a mentor, a self-help author. He understood her in ways no one else did. She quoted his writing lavishly and lovingly. He was full of proclamations.

''Dr. Hight says, 'We don't wear signs,' " she would say, and nod at his brilliance.

''Dr. Hight says, 'Expect a setback.' Dr. Hight says, 'Humor is your friend, and routine is an affliction.' " She would look to make sure I comprehended. Dr. Hight, I thought, needs to be fed to the fish. Dr. Hight is probably covered with liver spots.

I mentioned a new medication. ''I just want to stay the same," she said. The world was at fault; a pill would not fix its cosmic flaws.

She grew thinner, angrier, more bitter, eaten away. Now the parents of the neighborhood children were ridiculing her. They were inciting their children. It was raw conspiracy. Listening was painful; one felt filled with sympathy, until she redirected the attack personally. Then one felt she and Dr. Hight deserved each other.

Finally, and frankly with little hope, a change was made. Heaven knows why she agreed. The new medication was known for treating delusions. It was not known for treating bitter hearts. I worried she would develop a disfiguring rash or lose all her hair; some fine-print side-effect would further erode her beauty, which was the only defense she had. Dr. Hight would have a pithy thought about that. He would have made a note.

There were no dermatologic catastrophes. She seemed a little calmer on the next visit. ''I don't have that depression on Sundays," she said thoughtfully. A month later, she mentioned going to get a library card. She was interested in reading about the Revolutionary War. Done, I thought.

But she wasn't done. She came in recently, wearing an eggshell blue warmup suit and her little-black-dress earrings. They were slightly askew, not perfectly parallel. Her hair was undercombed. Her face was full of lines, or else empty of foundation and blush. But it was also utterly alive.

The neighbor had invited her for tea -- ''something we talked about doing for years, of course." She had brought the children candy, which was well received. She was going back soon. She felt peaceful, and reminiscent. She sat for a minute, smiling vaguely.

''I have a suggestibility, you know," she said. ''High school was the beginning of my nervous weakness. But I was happy, too. I remember a wedding I went to with my mother. For dessert, they had wedding cake and ice cream. Vanilla, chocolate, and orange ice cream. It was orange, not strawberry, and that made me so happy. I was filled with happiness that day."

She talked on and on. The therapist and I shared a glance. This was more than a medication effect. Was it false euphoria? The beginning of some undiagnosed mood swing? Or had the world turned its benign countenance to her, and had she recognized it for the first time?

''Follow for emergence of hypomania," I wrote dutifully in the chart. Diagnostic contingencies cannot be ignored. Heaven forbid.

She got up to leave. Rather impulsively, she put her arms around the therapist and kissed her. It was magnificent, a direct countercoup to theory. People change vastly, and for many reasons. It makes life worth living.

Elissa Ely is a psychiatrist.