We look for something called "aphasia." This is an inability to retrieve words. There's lots of different kinds of aphasias. There's paraphasia, which is trying to think of a word but coming up with another word that may sound similar or rhyme with the word. And then there's apraxia, which is the inability to control movement; and there's prosopagnaia, which is an inability to recognize familiar faces. We also look for perseverations--which comes from the root "to persevere"--which are a repetition of information that can show up in writing, speech or memory. For instance, if you asked "How's your salad?" and I said "It's delicious," and then you asked "Where are you going later?" and I said again "It's delicious" or you asked me how old I was, and I said, "Well, I'm delicious," or something like that--that would be a perseveration.

When I'm done with the testing, I write up a report which I then review with a neuropsychologist who signs it. Then the neurologist and the speech pathologist determine whether the patient needs therapy or not. Typically, where I work, they mostly want to put every patient in therapy. Therapy is kind of our bread and butter, it keeps the place going. The insurance companies like it too because they know it will help their legal cases.

In addition to the testing, I am involved in the rehabilitation therapy program here. I mean the actual administering of the therapy. We've designed a program for our patients which focuses on things that most people take for granted in daily life: concentration, insight, memory, word retrieval, things like that. The vast majority of the people here have found themselves suddenly imprisoned in their own bodies. It's hard for them to move, it's hard for them to remember to take a pot off the stove. Everything is thrown completely out of whack. Some patients are a little unruly, and diplomacy frequently comes into play, but mainly, these people need to be treated as human beings and not as victims.

The sessions usually last anywhere from fifty minutes to an hour and a half, although there are some patients that I spend the entire day with. It's obviously frustrating when the patient is very low-functioning and they have trouble going to the bathroom by themselves or you're sitting in the room with someone with aphasia and they can't come up with any words and can't talk to you. Or, if they have severe brain damage, their whole sense of identity, their whole sense of self has been erased and they have moment-to-moment memories, but they can't sustain a thought. They can't really remember in a conventional sense. It's like they live in a perpetual present. It's hard to teach people in that situation. It's hard to remediate someone like that.

On the whole, I think that therapy can help, but not dramatically. I mean we've had patients in therapy for five years. They improve, but we don't know how much of that is due to the organic flexibility--or plasticity--of their brain. I mean, it's hard to say how much we've actually helped. So I have my own therapy approach which is kind of different from how I'm expected or supposed to do it. It's based on the fact that generally, patients respond better to something they're interested in rather than the standardized materials that are designed for remediation--which in a lot of cases appear a little crude or insulting, especially to someone who is very intelligent.

The intelligent patients can sometimes benefit more from therapy than the low-functioning patients. So it's important to engage them. I've had patients who are playwrights, patients who are scientists, doctors, lawyers. Before their accidents, they were extremely high-functioning, intelligent people, used to being in control, used to calling the shots--and now they're incapacitated but still retain their intelligence.

So what I've started doing is to use their work to help them organize their lives again. I've had filmmakers who came in and we'd watch films and discuss them, break them down into scenes. I have a patient who's an investment banker and we talk about amortization and pro rata shares and we look at a textbook of investment banking. I find that this approach works very well. The patients really respond. It's also wonderful for me because I learn about all these different professions.

For the very low-functioning cases, almost anything that you can do to help is welcomed. I have a patient who fell on his head when he was eighteen and had a very severe closed brain injury. When he came here, he was in a wheelchair and was more or less a vegetable. I have to summon up a lot of energy to talk about this case because I kind of involve myself with my patients a lot. But with this patient, he has a few select catch phrases that he uses over and over again. He only really responds to what young adolescent boys like--Playboy magazines, cars, women, and things that have some indication of power or that can attract a woman, like a fancy car or a lot of money. He is totally driven by his id and that's all he is--a big id who can't really walk by himself.

When I came to him he'd been in therapy for three years, and he still hadn't really made any progress. I started a different form of therapy with him, sort of self-styled. I actually allowed him to see dirty magazines, took him to a Ferrari dealership. I played all kinds of games with him. I treated him like a man rather than a patient and talked to him about things. It was kind of like a mentor or big-brother relationship. I'd tease him, curse with him. I'd get him out of his wheelchair and I'd have him dance with me, and he couldn't keep his balance so I'd push him and grab him; or I'd have him cling to the walls and tell him that he was mountain climbing and he'd have to scale the walls. Radical kind of therapy, get right down to the fear--have him lie on the floor and try to get up.

You know, I tried everything I possibly could with him, including being sarcastic and teasing him--cause this is someone that you couldn't provoke a response out of. He was so impaired. He sat with his fingers all gnarled up and curled up with tension. He sat with drool coming out of the side of his mouth practically, always gaping with this woeful look on his face. There was some response; he could respond to fear and to pain and to pleasure, but he wouldn't remember it a minute later. You could tell him something and you could always feel safe that it wouldn't be repeated so you could virtually try anything. And now, a year later, he's really shown dramatic improvement. He uses a walker instead of a wheelchair, he doesn't curl his fingers, he can remember people's names.

He can talk but, for instance, if I say, tell me about your ideal woman, it can take him a while to come up with a response. But eventually, he'll say, she's gotta be blonde, she's gotta be blonde and she's gotta have big breasts. Before, he used to indicate with his hands when he meant breasts because he was afraid to say the word, but now actually he can say the word quite well. Everything just takes a while. I'll ask him to tell me the months or the days of the week and it could take two hours for him to get six of them in a row, and I'll do things like paste plastic vegetables to his face and body for every time he messes up. There was one day where he was completely covered in plastic vegetables. But he usually gets things eventually, although progress is slow and relative. If I ask him to name as many vegetables as he can, he'll name two and then he'll keep repeating the ones he just said. So he'll say banana, orange, potato, orange, banana, banana, orange, potato.

In the movies, they always try and give you this idea that the person who is trapped behind some mental roadblock knows that they're back there, and that everyone is a Helen Keller waiting to be born. And of course, that's not true. In this case, that's been a very big issue for me. I've been very conflicted over whether this kid was aware of a self--that there's a voice inside that he can articulate as easily as we can articulate this conversation, and yet he doesn't have the mechanism to articulate it just because his language area in his brain has been impaired and his memory is impaired. I mean, I'll ask him questions like: do you have a soul, are you afraid to die? Do you think you should live or die? Questions kind of like that, trying to out find out if there is a soul inside that he's aware of himself, that he's conscious of his own existence. And he is. He is.

So with this particular patient, it's sort of anything goes; any response is a good response, so any way to go about that was permissible. I did it myself and I convinced the people around me who reacted with a lot of--not alarm per se--but caution, and a lot of the other therapists were angry with me and felt I was being exploitative, but now they're doing the same thing. Everyone sort of has started to use my therapies that I've sort of invented myself.

Of course, sometimes it's very frustrating. It does get very personal and intense, and a lot of this gets into my bloodstream, and then I actually start to show signs or symptoms of the same conditions as my patients. I allow myself to be somewhat brain-damaged as a form of empathy. I go where my patients are as well as I can. There are times that I've been near breaking down, but that's part of the appeal for me, which is uncovering or being a kind of explorer into that realm. I feel that most professional psychiatrists and psychologists, the higher up they get, the less they really truly understand what it's all about because they're so focused on getting their degree that they miss out on the actual stuff.

Initially, this was a very fulfilling job for me. It's still rewarding, but on one level I feel like I'm a vampire because I take a lot of this for research--for my own research material--and then on another level, I'm really starting to wonder whether I'm helping the patients--if I'm capable of helping them anymore--because I'm starting to become just as bad off as they are in some respects. I allow my mind to wander off with them. I mean, there are days that I want to be engaged and help my patients genuinely and then the frustration kind of overcomes me and I say, I have to be a little more selfish about myself because so much of my time is focused on recuperation of other people, and I feel almost like I'm sacrificing myself for these people.

But I must say that there have been wonderful moments with these patients, beautiful moments. I have felt a wonderful feeling of getting to know one person. I mean we really learn by getting to know one person well. Of course the scales are tipped and I can risk an interaction with another human being in a way that my patients cannot. I mean, I'm in control always and it's not as much of a risk as if I just went out into the real world and dealt with people who were functioning normally.

I don't have any feelings like I'm going to save the world or discover the secret to schizophrenia--which I initially did when I started in this field. I mean, I was ambitious and I thought that I would really learn something and then maybe put that knowledge into another discipline--like theater or philosophy or something. But that didn't happen.

I still gather information, though, about the journey that the soul makes from dawn to twilight, the convolutions of the soul, what makes us tick, what the brain's like when it's unraveled. I try to find some spectrum that we all experience, and see its different intensities and different states, and thereby understand the puzzle or mystery of things. Though at this point it is kind of grating on me and I'd rather go out in the world and do something and perhaps have it shed insight on more people rather than just working with one person, because quite frankly, maybe I'm just too selfish at this point. I've considered possibly going back to school for a higher degree, maybe some branch of psychiatry where I could study schizophrenia only and just become a hard-core schizophrenia research scientist. I'll tell you, what really interests me is how people react in enclosed spaces. In an enclosed space when you put two people together, that's where the soul is made. That's my belief. When I'm dealing with someone who has no real defenses--where all of the subterranean stuff in their brain is exhibited, it's like being on the shore of the ocean, seeing everything get washed up, new things keep being brought to shore every minute. It's like all these shells that are in the brain that get smoothed and sanded by their journey from underneath to the surface, to the shore. They just keep washing up. You can just examine them and you don't know exactly where they've been completely. All you have is an echo of a former self.

You know, I don't think I'm actually gonna leave this field. Sometimes, I think I maybe want to be a patient, that's all. Actually, you know what I would really like to do? My plan really, which is kind of a contradiction to what I just said, would be to--well, it would be if someone was willing to give me millions of dollars. I would get a huge space somewhere. During the day I would see patients in a clinic and I would do drama therapy with them and experimental therapy with schizophrenics--patients who are like, lifers, who spend their life in hospitals. They're fascinating, beautiful people--I mean, I love schizophrenics. I would work with them and I would maybe have some research people there, too, who I would kind of hand pick. And then at night I would turn the space into a theater group. Like Yasnyia Polyana, Tolstoy's estate, which was inhabited by schizophrenics and actors--who are pretty much the same thing. I would be like the grand inquisitor, the overlord tyrant director and I would invite people from all over the world to put on plays and work on artsy films. Or maybe I would do a porno version of Plato's Symposium and make a million bucks.

This stuff has like a really strong grip on me and I feel like if I go too far away from it, I'm missing something essential about the human experience. This is my connection with nature in the modern age. If I spent too much time away from psychiatry, I could just get lost. Like right after college, I worked in an architecture firm, and I just felt so removed from nature. They say architects rarely get hard-ons, you know? I just feel that this kind of work keeps me connected really, and it keeps me humane, and it has enough darkness that it satisfies both my tendency towards good and it satisfies my darker nature as well. . . . . . . . . . . . . . .

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