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Introspections   |    
First Break
Richard M. Berlin, M.D.
Am J Psychiatry 2001;158:186-186. doi:10.1176/appi.ajp.158.2.186
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In a time before tabloid news, when shooting pool was inpatient psychotherapy, we drained long afternoons breaking the pack. Dave wore a work shirt and overalls, flashed a grin that tore his acned face when he cocked his head and heard the voices taunt. I was his age, a first-year resident dressed in a stiff dark suit to imitate my supervisors, still too inexperienced to know love can be sharp as the blade of a Bowie knife.

We played eight-ball in the shattered light, our young man banter billed as treatment. He told me the voices started when his girl flew out West, and I only half-believed he’d ever had her. Between shots, in the slash of time, he argued with the world he heard, and laughed the lonely laugh of the only man who gets a joke. At game’s end, the black ball buried in a corner, he’d stand heron-still, only his fingers chalking the cue. Then I’d rack the balls in their rigid triangle and wait for him to break.

I was learning in the half light of DSM-II. Though we didn’t tell patients their diagnosis, I tried to understand Dave’s illness through the new definitions of the Research Diagnostic Criteria, hoping if I could name his disorder with precision, I would be able to control it. To understand his medications I reviewed the latest psychopharmacology texts with their diagrams of dopamine drifting across the synaptic cleft like little billiard balls. And since I was coming of age during the transition from psychoanalysis to psychopharmacology, I studied Interpretation of Schizophrenia and Arieti’s explication of the principal of Von Domarus, still hoping words alone might cure.

One afternoon Dave’s lover returned, the blue-eyed, kilted girl next door, the kind of beauty that spills blood. We shot pool while her eyes studied him as if he were a broken watch, her voice cooing, "You’re wonderful Dave, but I’m not the one for you," while her hand snapped the eight ball from cushion to cushion. He chalked his stick, and she vanished like blue dust. Our game unfinished, we left the broken pack on the perfect green table.

For months we dissected the voices, and I stitched their words together with careful interpretations. Later, I tried to drown them with Stelazine, Loxitane, and Haldol, but their cuts were insoluble. Finally, taking a break from treatment, I sent Dave home with community follow-up, forgotten until the ER call, his crotch soaked with blood, his penis on a tray of ice.

All night, surgeons sewed skin thin as angels’ wings, and I restrained him with leather and kept him asleep with morphine. In the early morning hours at his bedside, I remembered our afternoons of eight-ball, the spheres scattering at random when we broke them, and I wondered about the source of our inner commands, the way certain voices break us to pieces, how biology’s fierce electricity can shatter a life. And a few days later, when I had to loosen the restraints, the commands intensified and he ripped out the sutures in a single pull, blood on both our hands, nothing in my power with the strength to bind him.

Address reprint requests to Dr. Berlin, 51 Church St., Lenox, MA 01240; rberlin@massmed.org (e-mail)

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