Becoming Myself: A Psychiatrist's Memoir

  CHAPTER SIXTEEN

  ASSIGNED TO PARADISE

  In August 1960, one month after finishing my residency at Johns Hopkins, I was inducted into the army. In those years the universal draft was in effect, but medical students were given the option of signing on to a deferment program called the Berry Plan, which allowed them to finish medical school and residency before entering the army. My first six weeks in the army were spent in basic training in Fort Sam Houston in San Antonio, and while there I was notified that I would be spending the next two years at a base in Germany. A few days later, another memo informed me that I would instead be stationed in France. And two weeks after that, mirabile dictu, I was told to report for service at Tripler Hospital in Honolulu, Hawaii. And that was the assignment that stuck.

  I remember my first moment in Hawaii with great clarity. As soon as I stepped from the plane, Jim Nicholas, an army psychiatrist, destined to be my close buddy for the next two years, placed a lei of plumeria blossoms around my neck. The scent rose into my nose, a sweet, heavy fragrance, and right there, I felt something shift within me. My senses awakened and soon I became intoxicated by the aroma of plumeria that was everywhere: at the airport, in the streets, and in the small Waikiki apartment Jim had selected for us and stocked with groceries and flowers. In 1960 Hawaii was a place of great natural beauty: the plumage, palm trees, hibiscus, red spiked ginger, white spider lilies, birds-of-paradise, and, of course, the ocean with its teal-blue waves gently rolling to rest on sparkling sand. Everyone wore strange and wonderful clothes: Jim greeted me wearing a flowery shirt, shorts, and sandals called zoris and took me to a Waikiki shop where I took off my army uniform, for a day at least, and walked out wearing zoris, a violet aloha shirt, and brilliant blue shorts.

  Marilyn and our three children arrived two days later, and together we drove to the top of the Pali Lookout with an otherworldly view of the eastern part of the island. As we gazed at the dark green crenellated mountains around us, the waterfalls and rainbows, the blue-green ocean, the endless beaches, Marilyn pointed down toward Kailua and Lanikai and pronounced, “This is paradise: I want to live there.”

  I was delighted by her delight. It had been a horrendous few weeks for her. During my six-week basic training in San Antonio, life had been hard for both of us, but particularly severe for her. We knew no one in San Antonio, where it was over one hundred degrees every day. I had a demanding daily schedule at the army school and was away all day five or six days a week, leaving Marilyn with our three small children. Things reached their low point when I had to undergo a week of basic training at a site a few hours from San Antonio. There I learned such invaluable things as how to handle weapons (I won a sharpshooter medal for rifle accuracy) and how to crawl low under barbed wire while live machine-gun bullets zoomed overhead (at least we were told they were live bullets—no one ever tested it). In those pre-iPhone days, Marilyn and I had no contact whatsoever during this time. When I returned, I learned that she had developed acute appendicitis the day after I left. She had been taken to the military hospital for an emergency appendectomy, while military personnel took care of our children. Four days after her surgery, the chief surgical resident paid a home visit in the evening to tell Marilyn that the pathology report indicated she had an intestinal cancer that would require major resection of the large bowel; he even drew sketches for her to show me indicating the parts of the bowel to be removed. When I returned home the following day, I was shocked by the news and the surgeon’s sketches. I rushed to the army hospital and obtained the pathology slides, which I sent by special delivery to physician friends back east. They all agreed that Marilyn had a benign carcinoid tumor that required no further treatment whatsoever. Even now, fifty years later, as I write about it, I feel great anger toward the army for not notifying me, and for suggesting major and irreversible surgery for a completely benign condition.

  All that was behind us now as we looked out over the mountains and the light blue water in this new setting, and I was thrilled and relieved to see the lively, vivacious Marilyn back with me again. I looked again toward Kailua and Lanikai. Living there would be entirely impractical: we had very little money and the army offered inexpensive military housing at the Schofield Barracks. But I was as enchanted as Marilyn and, within a few days, we had rented a small house in Lanikai one block away from one of the world’s most lovely beaches. The Lanikai beach has taken up permanent residence in both of our minds: it remains the most beautiful we have ever seen, and ever since, whenever we walk on a beach with powdery but firm sand, we look at each other and say, “Lanikai sand.”

  Long after we left Hawaii, we returned regularly to that beach, which now, alas, has been greatly eroded. We lived there for one year, until we learned that an admiral had unexpectedly been reassigned to the South Pacific, and his house on the neighboring Kailua beach was for rent. We immediately rented it and were so close to the water that I could be surfing or snorkeling while I was on call: Marilyn would signal that I had a phone call by waving a large white towel from the veranda.

  Shortly after we arrived, we received letters of greeting from three generals, based in Hawaii, Germany, and France, each welcoming me to their post. The initial confusion about my posting led to many of our belongings being lost somewhere in transit, so we truly had a new start—we bought all our furniture and bedding from a garage sale in a single day.

  My army duty was undemanding. I spent most of my time in an inpatient unit with patients coming from various Pacific bases. In 1960, the Vietnam War was yet to come, but many of our patients had seen unofficial military action in Laos. Most of those with serious mental illness had already been screened out and sent directly to stateside hospitals. Hence, many of our patients were young men who were not psychotic but pretended to be, hoping to get a discharge.

  One of my first patients, a sergeant with nineteen years of service who was near retirement, had been arrested for drinking while on duty—a serious charge that might threaten his retirement status and pension. He came to me for an examination and incorrectly answered each question I asked. But every one of his answers was so close to the truth that it seemed that some part of his mind knew the correct answer: six times seven was forty-one, Christmas Day was December 26, a table had five legs. I had never seen such a case before, and through speaking to colleagues and searching the literature I learned it was a classic case of the Ganser syndrome (or, as it is often known, the syndrome of approximate answers), a type of factitious disorder in which the patient mimics an illness when he is not really sick but may be trying to avoid responsibility for some illicit act. I spent much time with him in his four-day stay (patients who needed longer hospitalization were shipped back to the continental United States), but could never make contact with his non-deceiving self. The really strange part, as I learned from my study of the literature on the long-term follow-up, was that a high percentage of Ganser patients did, in fact, develop a true psychotic disorder years later!

  Every day we had to make decisions as to whether some soldier was truly mentally ill or faking it in order to get a medical discharge. Almost every patient that came to us wanted out of the army or navy or marines—we treated all branches of the military—and my colleagues and I were troubled by the arbitrariness of our decision-making process: guidelines were unclear, and there were times when we were inconsistent in our recommendations.

  The duty requirements were exceedingly light compared to my internship and residency: after four years of being on call evenings and weekends, I felt I was on a two-year holiday. There were three psychiatrists, each on call every third night and weekend; I had to go to the hospital at night only a few times during my entire tour of duty. The three of us related well to one another and to our commanding officer, Colonel Paul Yessler, a genial, well-informed colleague who allowed us full autonomy in our work. Though our psychiatric unit, Little Tripler, was only three hundred feet from the large Tripler Hospital,
it had a relaxed, nonmilitary atmosphere. I ate lunch at the large Tripler and occasionally did consultations there for other services, but otherwise rarely set foot in it, and often I went for weeks without receiving or giving salutes.

  Given this freedom, I chose to continue my interest in group work and formed a variety of therapy groups: daily inpatient groups, outpatient groups for troubled military wives, and, in my off-time, a process group for nonmilitary psychiatry residents at the Hawaii State Hospital in Kaneohe.

  I felt most useful in my groups for military wives. Many of them were dealing with being away from their accustomed surroundings, but some chose to engage in deep work exploring their loneliness and their inability to make connections with others in their community. The resident group was far more difficult. The residents wanted a therapy experience that would be both personally therapeutic and instructive for them as group leaders. They had heard that I was an experienced group therapist, and asked me to lead. I was uneasy: I had never led this kind of group and, moreover, was only a year or two more experienced than they, but since the residents were motivated enough to request it, I agreed to do it. It was not long before I realized I had gotten myself into a difficult situation. A group will not work unless members are willing to take risks and disclose intimate thoughts and feelings, and this group was extremely reluctant to take that step. Slowly I began to understand that, since the therapist’s chief professional tool is his or her own person, self-disclosure of personal shortcomings felt doubly risky: not only might one’s character be judged, but one’s professional competence as well. Though I became fully aware of this conundrum, I could not resolve the impasse, and the group was only moderately successful. In the future I came to the realization that to be an effective leader in such circumstances one must be willing to model self-disclosure by taking personal risks oneself in the group.

  I have no doubt that my two years in Hawaii changed my life. Before then, my long-range plans were to return to the East Coast, perhaps, as Dr. Whitehorn had suggested, to seek an academic position, or to rejoin my friends and family in Washington, DC, and enter private practice. But after a few sunny Hawaiian months, the cold, gray, formal East Coast grew less and less inviting. For years, Marilyn had wanted to move far away from Washington, and soon we were in full agreement: we both wanted to remain in Hawaii, or as close as possible. Before Hawaii, my entire life had focused on my work, with far too little time for my wife and children. Hawaii opened me up to the beauty of my surroundings. The beaches, especially, beckoned, and Marilyn and I walked on them for hours, holding hands just as we had in high school. I spent much more time with my children, a good bit of it in the warm ocean, teaching them to swim, snorkel, and body surf. (I never mastered surfing on a surfboard—I didn’t have the balance.) I took my children to our neighborhood cinema on Friday evenings to watch samurai films, and they wore their pajamas just like the local kids.

  The army would not ship my Lambretta to Hawaii, but was willing to ship a telescope, so, while still in Baltimore, I had traded the Lambretta for a mechanized eight-inch reflecting telescope, something I had coveted since my childhood forays into telescope making. However, aside from a couple of times when I lugged it to the top of a mountain, I could make little use of my telescope in Hawaii because of the persistently hazy Hawaiian night sky.

  One of my patients was the flight controller at the army air force base, and through him I enjoyed the perk of hopping weekend flights to the Philippines and Japan. I did some snorkeling in the exquisite waters off a small island in the Philippines, and saw sunsets in Manila that remain forever in my mind’s eye. I stayed at the officers’ club in Tokyo and explored the city. Whenever I was lost, I hailed a taxi and showed him the club card with the address written in Japanese. I had been warned by the club manager to watch the driver when I showed him the card: if he inhaled sharply, then I should jump out of the cab, as Tokyo taxi drivers would not lose face by admitting they didn’t know an address.

  Shortly after our arrival, Marilyn obtained a faculty position at the University of Hawaii French Department. She was especially delighted to teach a course on contemporary French literature with so many Vietnamese students fluent in French, even though they had great difficulty grasping Sartre’s ideas about alienation, as they were planning to swim after class in the warm blue ocean. Marilyn needed our car to drive to the university, so I bought a peppy Yamaha motorcycle and was thrilled with my thirty-minute morning commute to Tripler over the top of the Pali. During our time there, the Wilson Tunnel through the mountains opened, and I then took that shorter route to work and had the daily experience of entering it in bright sunshine and emerging almost always in the midst of a delicious, warm Hawaiian shower. Close to my home in Kailua there was a small tennis club with grass courts where we played against other clubs on weekends. One of my army friends introduced me to snorkeling and scuba diving, and, for the next forty years, I was to derive great pleasure from gliding along the ocean bottom, admiring the fauna and the life of sea critters in Hawaii, the Caribbean, and many other parts of the world. A few times I went night diving, a special thrill, since all the nocturnal creatures were on the prowl, especially large crustaceans.

  Jack Ross, one of my army colleagues who had trained at the Menninger Clinic, introduced me to his classmate, K.Y. Lum, a psychiatrist in practice in Honolulu. He and I organized a case presentation group with several Hawaiian psychiatrists who met monthly. We also started a psychiatrist poker game held every other week and persisted for three decades. K.Y. and I became close friends and remain in touch to this day.

  One day, during my first weeks in Hawaii, André Tao Kim Hai, an elderly Vietnamese man who lived around the corner, stopped by my house carrying a chess set and asked, “Do you play chess?” Manna from heaven! André and I were evenly matched and played dozens and dozens of games. He had retired to Hawaii after serving many years as the Vietnamese representative to the United Nations, but a few years later, when the Vietnam War broke out, he left the United States in protest and moved to Paris, and then to the island of Madeira. We continued our friendship and our chess rivalry in later years when I visited him at both of his later homes.

  My parents visited us in Hawaii, as did Marilyn’s mother and my sister, Jean, and her family. Marilyn made friends at the university and for the first time we developed a social life, forming an eight-person salon with sociologist Reuel Denney, coauthor of The Lonely Crowd, and his wife, Ruth; the Indonesian philosopher and poet Takdir Alisjahbana and his German wife; and George Barati, conductor of the Hawaiian Symphony Orchestra, and his lovely wife, another Ruth, a yoga devotee. We spent many happy evenings with them reading translations of Takdir’s poetry, discussing one of Reuel’s books, listening to music, or, one night, listening to a tape of T. S. Eliot reading The Waste Land, which left all of us dejected. To this day I remember our little group having a luau on the beach, enjoying Hawaiian drinks and guava, lychees, mangos, pineapple, and papaya, my favorite. I can still recall the flavor of Takdir’s beef skewers dipped in his Indonesian peanut sauce.

  With poker, snorkeling, beach walking, motorcycling, playing with my children, and chess, I led a far more playful life than I ever had before. I loved the informality, the sandals, the simple act of sitting on the beach and staring out to sea. I was changing: work wasn’t everything. The gray East Coast, with its frigid winters and oppressively hot summers, no longer beckoned. I felt at home in Hawaii and began to fantasize about staying there for the rest of my life.

  As we approached the end of our two years in Hawaii, we were faced with the decision of where to live. I had published two more professional articles and was leaning toward an academic career. But, alas, staying in Hawaii was not an option: the medical school offered only the first two nonclinical years and had no full-time psychiatry faculty. I felt very much on my own and sensed the lack of a mentor, someone who might have given me guidance about how to proceed. Not for an inst
ant did it occur to me to contact my Hopkins teachers, John Whitehorn or Jerry Frank. Now, as I look back upon that time, I’m mystified: Why didn’t I think of asking them for advice or for a reference? I must have thought that I had passed entirely out of their minds when I had finished my residency.

  Instead, I took the least imaginative path possible: the want ads! I checked the ads in the American Psychiatric Association newsletter and found three postings of interest: faculty positions at Stanford University School of Medicine and the University of California at San Francisco (UCSF) Medical School, and a staff position at the Mendota State Hospital in Wisconsin (of interest only because the eminent psychologist Carl Rogers worked at that hospital). I applied for all three positions. They all agreed to interview me, and I caught a military plane to San Francisco.

  My first interview, at UCSF, was with a senior faculty member, Jacob Epstein, who at the end of an hour offered me a clinical faculty position and an annual salary of $18,000. Since my third-year salary as a resident had been $3,000, and my military salary $12,000, I was inclined to accept, even though I knew the demands on my time would be very high: I would not only be teaching medical students and psychiatric residents, but also running an extremely large, busy inpatient ward.

  The following day, David Hamburg, who was the new chairman of the Stanford Psychiatry Department, interviewed me. The Stanford Medical School and Hospital had just moved from San Francisco to newly constructed buildings on the Stanford campus in Palo Alto, and he was given full charge for creating an entirely new department. I was struck by Dr. Hamburg’s lofty vision, his concern about our field, and his wisdom. And by his sentences! Hearing one stately, complex sentence after another roll off his tongue was like listening to a fine concerto. Furthermore, I had the strong sense that, in addition to his mentorship, I would be provided with all the resources and academic freedom I needed.