The office is hardly what one expects of a psychiatrist on Connecticut Avenue. It is shabby and cramped. The white walls are soiled. The blue rug is ratty. The electric clock used to time therapy sessions has a broken crystal.
After he admits a patient, Dr. Harold I. Eist shuts the soundproof, double doors and eases into a worn black Naugahyde swivel chair. While the office is small, the psychiatrist-- weighing in at 210 pounds--is not. With Eist and a patient sitting almost kneecap to kneecap, the room is crowded.
Behind the soundproof doors, patients tell their psychiatrist things like this:
"I'm so depressed that I might not even talk," warned Regina Turner, 45, and unemployed. Then she started talking. She said she is "born again" and has stopped carrying a dagger and a hammer in her purse. She made no apology, however, for threatening her former psychiatrist with the hammer. "He was a racist," she said. She warned Eist about "torment for eternity" if he doesn't get born again himself. She mentioned a postal worker she believes is stealing her copies of Psychology Today, and she vowed to "bust him upside the head." She said her medication, an antianxiety drug called Xanax, is working.
"I peed the bed one time," said Clarence Taylor, 14. He said "nothing" was going on in school, but he had been fighting with his brother. "We fought over TV. My dad got the belt and he beat us. He's been doing that since my mom told him off." Taylor, who was sexually abused as an infant and who recently beat up his 3-year-old cousin, admitted he wasn't taking his medicine, an antipsychotic called Mellaril. He promised to take his drugs and bring his mother in next time.
These two pseudonymous patients are part of a parade of 1,200 patients that passes each week through the three clinics of the D.C. Institute of Mental Hygiene. It is, by and large, an unhappy parade. The patients are severely depressed, schizophrenic, hyperactive, afflicted with personality disorders. Their illnesses are complex, often unattractive. Many of them are poor, inarticulate, suspicious. They are angry--at Eist, at themselves, at voices inside their heads--because they are not getting "better." Most of them, however, are improving--slowly.
They are all outpatients. When their sessions are over, after they receive prescriptions for psychoactive drugs, they walk outside and try to live in the so-called normal world.
With the consent of the patients, a reporter sat in Eist's office while the psychiatrist saw 31 patients. None of them became violent, none was cured. Few looked mentally disturbed. Words--not open wounds, X-rays or blood samples--were the evidence of illness.
The patients who come to the D.C. Institute are, on the average, poorer, less insured and more seriously ill than those who frequent the offices of most private psychiatrists and psychologists in Washington.
"We don't have patients that I would put in the category of the 'worried well,'" said Carol Purcell, administrator of the institute. "They have been to church, to their family, to hospitals before coming here. The people we see are here out of desperation."
One of three patients at the clinic has been hospitalized for mental illness; half receive psychoactive drugs. Half are black, seven percent are Hispanic and the rest are white. More than half the patients earn less than $15,000 a year.
The first patient on Monday was Charles Lum. Called out of the waiting room, he lumbered into the psychiatrist's office, sat down and folded his arms tightly against his massive chest.
It had been a bad week for Lum. He had been driving to work on the shoulder of the road and he didn't know why. The pills that are supposed to prevent fluid from building up in his stomach and legs were not working. His stool was bloody. The trigger for all this was Carl, his teen-age son. Carl had been kicked out of school for smoking.
"I thought leaving home yesterday, 'Why should I go through this heartache with Carl?' I thought I should shoot myself," Lum said.
During the next 50 minutes, Lum spoke of his failures as a father, his inability to forgive his nine children or to show them love. About 25 minutes into the session, he began to sob. His shoulders convulsed and his nose ran. He belched. Tears and mucus dripped from his face to the carpet.
"You have this primitive tendency to rip your guts up," Eist said at one point.
"I've had 52 years of practice," Lum replied, crying.
After Charles Lum wiped away his tears and blew his nose, he announced that he was feeling better and he walked out. After he left, Eist said he felt "achy," needing an antacid. "A psychiatrist is a person who sits and contains pain all day long," Eist said.
Lum's session with Eist cost $50 (the clinic's highest fee) and was paid for, except for $8, by Lum's Blue Cross- Blue Shield federal employe insurance. Most of the clinic's patients neither have such good insurance coverage nor qualify for Medicaid. Fees for them are based on ability to pay. Patients making less than $10,000 a year, nearly 40 percent of the clinic's caseload, pay an average of about $7 out of their own pockets for an hour of psychotherapy.
As the afternoon wore on, the procession of patients continued:
Pamela Kosinski, 24, is an overweight "borderline depressive" whose jaw sometimes locks shut when she is nervous. ("Borderline" refers to "borderline personality disorder," a vague, controversial diagnosis describing a patient with unstable moods, inappropriate anger and a disturbed self-image.)
"My father, out of the goodness of his heart, told me what kind of drugs I should take," Kosinski said, nervously fingering a copy of a U.S. News & World Report article on depression. Her father read it, she complained, and presumed to diagnose her depression. Eist asked if Valium, along with her antidepressant medication, was relaxing her jaw. Kosinski said yes.
John Newton, 30, is a seven-year veteran of the clinic, a "borderline depressive" who works at several part-time jobs while studying for a master's degree.
"Last week was very stressful. I tend to freeze up when my boss comes near me, plus I wasn't totally prepared," Newton said.
While Eist had acted paternal and warm with Kosinski, he was cool with Newton. The reason, Eist explained later, was because he'd had a falling out with Newton several years ago.
"He called me up once on New Year's Eve and asked if he could ask out his therapist. We had an angry exchange. I told him to find his own dates. Since then he's told me to lay off the interpretations," said Eist.
Eist leaves the interpretations up to Newton's psychiatric social worker, who sees him once a week at the clinic for an hour of psychotherapy. Since there are only 10 psychiatrists (who can prescribe drugs) at the clinic and 87 psychologists and psychiatric social workers (who can't prescribe them), most of the psychiatrists' time is taken up in 15-minute drug review sessions. Most clinic patients see a psychiatrist once or twice a month. Eist's entire week, except for his hour with Lum, was taken up by these brief but intense sessions.
Newton, despite his run-in with Eist, never stopped coming to the clinic. He no longer threatens suicide. His medication has been reduced from 150 to 40 milligrams a day of Elavil, an antidepressant. His experience shows, Eist says, that seriously ill patients do get better.
On Tuesday Eist began his day with a staff seminar. For two hours in a conference room adjacent to his office, Eist lectured nearly 30 therapists on such things as the concept of the "normapath" (children washed of uniqueness by trying to be too normal), on the temptation to condemn a patient's family and on Freud.
"Freud's behavior with his patients would horrify most analystsg," Eist said. "Freud could ignore the rules because he was an explorer, an innovator. That's why we are all in this business. We are explorers, investigators, innovators."
Two days later Eist drove to the D.C. Institute's clinic in Anacostia, where patients are nearly all black and nearly half are children. In an office there, Eist saw 10 patients, six of them children.
Julie Green, a hyperactive 9-year-old with blue ribbons tied to her pigtails, came in with her mother. As Eist and her mother discussed Julie's latest report card, the girl flitted around the office, tugging at her pigtails, leaning over Eist's desk, banging her elbows against the walls. Julie has been coming to see Eist, on and off, for four years.
Mother: "She plays with her friends and when they make her mad, she'll smack 'em."
Eist: "Are you still doing that?"
Julie, Eist says, is functionally retarded, may be moderately neurologically impaired and is abnormally dependent on her mother. The mother, divorced and on welfare, dotes on Julie, her only child.
"Julie is hyperactive toward the psychotic end of the spectrum," Eist said later. "She is likely to have problems her whole life because our science is primitive and we don't have sophisticated tools. Her mother's expectations are such that when Julie reaches a certain level of functioning, she is satisfied and sees no need to continue. The mother feels she might lose Julie if she gets too well."
In the office, Eist told Julie's mother that she must keep her daughter in therapy and make sure she continues to take her Mellaril, an antipsychotic drug.
Back on Connecticut Avenue, seven more patients came in on Friday for medication checks.
Among them was Carlotta Rodriguez, 30. Chronically schizophrenic nine years ago, she has improved dramatically. She has a job with the federal government, her night terrors have disappeared and her medication has been reduced. She lives now in the so-called normal world. In that world, her boyfriend has cancer of the pancreas.
"He is going to die," Eist said bluntly. "You have to prepare yourself."
"I know," she replied, her voice halting, her face sagging with "normal" grief. "I know."