Chapter 44: I’d Worry About Your Soul

January 12, 1985, Greater Cincinnati, Ohio

"You came alone?" Doctor Mercer asked when I walked into her office in Milford.

"I did. I'm going to see Angie's pastor after you and I finish our session."

"Did you tell Elizaveta you were going to be here?"

"Yes."

"Did you tell her WHY you were going to be here?"

"No. That seemed to me to introduce unnecessary turmoil. I did tell my bishop and priest about the situation."

"That's unexpected. Why tell them and not her?"

"I saw my bishop on Sunday, and when we were talking, he said that if I was struggling with anything, I should speak to my priest or to him directly. It felt as if he had discerned from our conversation, which had nothing to do with Angie that I had some kind of internal struggle about which I wasn't speaking to anyone. I told him what had happened, and after asking me if I was considering the ramifications of saying 'no' or of saying 'yes', he sent me to talk to my pastor. Father Nicholas prescribed a fairly strict prayer and fasting rule to help me focus."

"And did it?"

"In the sense that I didn't really think about Angie's question until I left campus this morning to drive here, yes. I wondered about that and realized that what Father Nicholas intended was to keep me from obsessing about it until I could speak with you and Father Stephen."

"And knowing you, you would have obsessed, to the detriment of your school work and likely to your relationship with Elizaveta. Pretty wise, don't you think?"

"Yes. Both the bishop and Father Nicholas were clear I should speak with you and Father Stephen — secular and spiritual help, in synergy."

"A far cry from the fundamentalists who basically think psychology is the Devil's work."

"You know we don't think that way; as the bishop has said in a homily, a miracle by a doctor's hand is no less a miracle."

Doctor Mercer nodded, "Something which was demonstrated a few weeks ago when a very dear friend and former patient nearly died in a terrible accident. Flight for Life and a trauma surgeon in Indianapolis saved her life when by all rights she should have died."

"Indiana University Hospital?"

"Yes."

"We interviewed there, and the acceptance letter was signed by a Doctor Albert Barton, a trauma surgeon."

"That's the one who saved her life in what should have been an impossible situation."

"Small world," I replied. "Will she make a full recovery?"

"Her injuries were obviously severe, but they think so, yes."

"That's good to hear. I suppose we should talk about Angie. How is she?"

"That all depends on the reason you're asking."

I shook my head, "I don't believe that at all. I believe you're concerned that I'll take your answer either as permission or as an attempt to deter me. Do you think I'm that weak-willed?"

"I think you're in love with Angie, and I think that might blind you to the reality of the situation."

"Because that's been my pattern of behavior? What happened when she asked me to make love with her?"

"There was something about the way you spoke on the phone that says this is different."

"Perhaps it was, but I DID call you before I did anything else; well, I talked to Clarissa, but that's because it was New Year's Day, and I waited until the next morning to call you. I also know that no matter what I decide, it's going to have consequences I can neither predict nor control. So, how is she?"

"One question — is this therapy or, and I say this advisedly, collegial?"

"Collegial. You have my permission to be as blunt as you need to be."

Doctor Mercer nodded, "On the surface, Angie is exactly as you believe she is."

"I did think a bit about what you said on the phone, and I want to ask you how long someone would have to go with no symptoms to say they were no longer suffering from the illness?"

"Mental illnesses don't work that way, Mike. Well, not the one we believe Angie has. In general, there are three types of conditions — ones which are persistent, ones with relapses, and ones that are one-time events. Generally, the ones in that latter group are the kinds of things people seek short-term counseling for, similar to our occasional sessions. You had a series of traumatic events which caused acute distress but which, once resolved, were no longer a concern, at least with regard to depression or something similar. Do you agree?"

"I think so, yes."

"And the same is true for your friend Jocelyn, right?"

"Again, I think so."

"On the opposite end are the persistent conditions — the ones that often require drugs, hospitalization, and some kind of long-term, professional, assisted care."

"I'm not sure what the correct word is, but you mean people have to be committed to a mental hospital?"

"Basically, yes, and the term mostly being used now is 'institutionalized'. As for Angie, she's in the middle group, and given her diagnosis, she's in the twenty percent who are able to function somewhat normally day-to-day. But, she's also exhibiting one of the typical effects of schizophrenia — non-compliance with treatment. In her case, it's trying to stop the drugs even when she needs them. She's also deceiving herself about her ability to teach. She's doing a basic, repetitive job that doesn't require a lot of thought."

"And her classes?"

"When she's in control, she can do them; but Mike, her onset of symptoms was earlier than is typical for females by about five years. And while she seems to be better, you've seen this before; twice, in fact. Those two breaks occurred under stress — not just relationship stress, but also school, as well as other things. Right now, her life is managed, almost minute to minute, and her stress levels are monitored and regulated. That kind of close, minute-to-minute support is going to be necessary for the rest of her life, and she'll very likely still have breaks when stress builds up, which means a course in psychoactive drugs each time that happens.

"That's the reality, Mike, no matter what it looks like right now. Any future you might have with Angie would require constant attention on your part, and to be blunt, there is no way a medical student or Resident can give her the care and attention she needs. And that's assuming she can actually have the kind of relationship she's asking for, which is, in my estimation, unlikely. Oh, she might get as far as consummating, but at some point, some stress will occur, and she'll have that break."

"You seem so convinced of that future," I said. "But you also said she's in the twenty percent who function in society."

"Yes, by reducing stress, but even that twenty percent have breaks. If you're going to do this, Mike, you're going to have to give up pretty much everything."

"I never said I was," I replied.

"You never said you weren't, either, and our conversation didn't seem as if you were playing Devil's Advocate. You also said you told your bishop you were contemplating it."

"By saying I was considering the ramifications of either answer. You've taken me through what I can expect if I were to try; what happens if I turn her down?"

"I can't predict the future, but it's certainly going to increase her stress levels."

"Five percent of all schizophrenics commit suicide," I said quietly.

"How much reading did you do?"

"I read ahead in my Abnormal Psych text, then on Thursday morning, I went to the campus library and did some research."

"So you knew everything I just told you because it basically comes straight from the textbook."

"I did."

"And your conclusion?"

"Clarissa observed, immediately after you and I spoke, that becoming Doctor Mike trumps being Deacon Mike, Daddy Mike, and every other possible incarnation of Mike. She asserted that I would choose celibacy over giving up on being a doctor. Everything else has to take a back seat."

"Do you agree with her?"

"Maybe not on celibacy..." I smirked.

"I hope you've kept your word to Elizaveta AND to your pastor."

"Are you asking me to make a confession?"

"Do you NEED to make a confession?"

"Only to thinking about Angie when I'm engaged to another girl. Celibacy isn't an issue."

"You can turn that on and off, like a light switch?"

"Apparently so."

"Then why not make use of that ability before you get engaged?"

"I chose not to. I could blame my weakness, but I'm responsible for my own decisions."

"And when you turn it back on, will you be able to control it?"

"In the sense that I'll limit myself to my wife, yes."

"That's a different story from the one you told me during our counseling sessions. You were worried that was going to be your downfall. I certainly can't see you drinking, and you don't have the personality type for narcotics. You do, on the other hand, have the personality for, and a history of, casual sexual relationships and multiple partners during the same time frame. Stress is unavoidable, and our personalities dictate how we respond. In the ER, you're going to be one cool customer. Outside the ER is where I have my concerns."

"You're saying the temptations will come fast and furious?"

"I'm saying it's not even going to be a temptation, but outright attempts at seduction. I've seen it. There will be young women who will simply throw themselves at you."

"Good to know," I replied with a grin. "But I don't respond well to that kind of approach."

"No, you don't. If you slip, it'll be without even realizing what is happening until you find yourself in a situation which, if not physical, will be emotional, and in some ways that's even worse."

"That has been suggested."

"What I'm trying to tell you is that you can't be cavalier about this. Fine. You can turn off your libido. But libido isn't what will cause you to slip, Mike. It's your psyche, and that is something much more difficult to control."

"That has also been suggested by me, in fact. It all starts with a stray thought."

"Then why were you so confident before?"

"You were talking about libido, which I will be able to control, mainly because of a certain sexy, soon-to-be sixteen-year-old girl! It's the emotional connections I have to watch. And I'll have help from Clarissa and Jocelyn, along with my accountability to my priest. I'll have to be on my guard at all times. So, now that we have that out in the open, what is Angie going to do?"

"I can't answer because I don't know. I'm not a mind reader."

"But there are risks."

"Yes. She's likely to have a break."

"Wonderful," I sighed.

"Mike, she's destined to have a break in the future no matter what happens. And you are NOT responsible, and neither is she. It's her illness, and we have to manage it."

"Easy for you to say, difficult for me to internalize."

"There is a larger issue."

"Oh, I know," I sighed. "How any interaction with me might affect her in the future, and should I even see her? I thought about that on the drive here. I have this feeling that I have to marry her or never see her again."

"To be honest, I don't know the answer to that question," Doctor Mercer said. "All we can do is wait and see. Can you handle not seeing her again?"

"Discounting the other option?" I asked with an arched eyebrow.

"Unless you're a complete fraud, and I don't think you are, nor are you that good of a liar, then yes."

"I'll take that compliment," I replied. "It would be difficult, but if that's what's necessary, then I'll do it. The question is, will SHE do it?"

"Again, I don't know. We could completely control her actions if we prescribe the antipsychotics, but we really don't want to do that except when she has schizophrenic episodes. A permanent course of drugs WILL bring about serious side effects, and we want to avoid those if we can."

"This sucks," I sighed.

"Not to take away from your personal feelings, but think about how it must be for her."

"Sorry, I'm not trying to have a 'pity party' for myself. I care for Angie."

"You mentioned talking to her pastor."

I nodded, "I knew she'd need spiritual help no matter what decision I made."

"When did you actually decide?"

"When I walked in the door of your office."

"Sadly, I believe that. Your heart is that conflicted?"

"You know how much I love her..." I sighed.

"But..."

"Clarissa was right — I want to be a doctor more. I feel like a complete cad."

"May I be direct?"

"Sure."

"How many relationships have you ended for exactly that reason? Or didn't start? You actively tried to chase off girls until you found one you couldn't chase off."

"I didn't chase Angie away. I didn't really try."

"Mike, none of that was real. I'm not saying Angie wasn't sincere, but there's no way to know what's real in Angie's mind and what isn't. I'm sure you read that schizophrenia is, among other things, a disorder of the sense of self and that while schizophrenics observe, they do not properly process observations into meaning."

"But it felt so real. And my love for her is real."

"I don't doubt your love, but for Angie, her sensations, thoughts, ideas, and understanding of the world are incoherent during her episodes. And outside those episodes, she doesn't see or process the world the way you and I do. Her reality is not our reality. She doesn't implicitly understand her thoughts the way you and I do."

"I don't understand my thoughts at times."

"Yes, of course, and that's normal. But what's the definition of a diagnosable illness?"

"When things which might be common to all of us interfere with our ability to function in society."

"At one time or another, you'll exhibit some of the markers for just about every mental illness. The most common one is depression, and usually, it's dealt with by short-term counseling. Clinical depression is a very different thing."

"I know."

"Going back to Angie, her behavior fits a number of things in ICD-9, the ninth revision to the International Classification of Diseases. For example, compulsion, which involves rituals."

I couldn't help but laugh, "Then every Orthodox Christian on the planet is mentally ill!"

Doctor Mercer smiled, "This is where I say, 'You said it, not me!' and yes, I know you use those rituals as a coping mechanism at times. And that's healthy. It's not a coping mechanism for Angie; it's a compulsion. Do you see the difference? The things you do each day, your rituals, help you put order in your life, and while you might feel a bit out of sorts if you miss them, you can rationally decide not to do them and not have a breakdown."

"I was teasing, and yes, I do see the difference."

"Another common symptom is one you should recognize from before she had her break — the future is blocked, and existence seems to be dominated by either the present or the past. And, of course, anxiety caused by fear, in her case, fear of sex. I'll give you one more, too. Please don't read this the wrong way, but major worldview shifts, including adopting a new religion, that don't occur during a manic or depressive phase are another marker."

"Shit," I sighed. "All the symptoms were there. How could I miss them?"

"First of all, when did you start swearing in English?"

"About the time Tasha got engaged to Nik. I rarely use Russian, except for my pet name for Elizaveta — «Котёнок» (katyonak)." ("Kitten")

"And second," Doctor Mercer continued, "every single one of Angie's symptoms, taken individually, are things people do all the time. And remember, all of these are basic symptoms which occur before the onset of psychosis. They occur and disappear, exactly as you've seen. But think about all of those things, and think about how normal they look. For example, I suspect you don't send all your converts for a psychological evaluation."

I chuckled, "Are you suggesting they all need their heads examined?"

"Again, 'You said it, not me'," Doctor Mercer replied with a smile. "But no, I suspect most are dealing with some kind of existential question, and that's normal. But Angie didn't convert because of an existential question."

"No, I guess she didn't. I still feel as if I've failed her and that I'm about to fail her again."

"Are you feeling selfish?"

"I don't know if that's the right word, but it sure sounds as if I am when I put being a doctor ahead of everything."

"It's an interesting problem — the very trait that will make you a good doctor, and one which society values, is the one that has great potential to sow the seeds of your own destruction."

"The relationship problems we hear about with regard to doctors."

"Very much so. And I will point out that you have backed off a bit on that single-minded focus, at least enough to attract the attention of young women."

"A few of whom regularly beat me about the head and shoulders because of that single-mindedness. And that was, in the end, why Tasha and I couldn't marry. Her single-mindedness and mine clashed."

"Yes, though I suspect if she'd been two years younger, she might have been able to adjust her own goals enough to make it work."

"Not once the bishop asked me to become a deacon. Tasha's experience living in her dad's household pretty much put paid to that idea."

"But you could have told the bishop 'no' if you wanted to marry Tasha."

"Could I?" I asked.

"Now we're getting into an area where, if this were counseling, I'd be ethically bound to keep my mouth shut."

"But this is 'collegial', as you said."