GIRL, INTERRUPTED

Girl, Interrupted is Susanna Kaysen’s memoir. In this book she writes about her experience as a psychiatric patient in the 1960s. Susanna was an 18-year-old female admitted to McLean Hospital, in Belmont, Massachusetts, after making a suicide attempt. Susanna was born and raised in Cambridge, Massachusetts. She attended high school at the Commonwealth School in Boston and Cambridge School. She was a daughter of the economist Carl Kaysen, a professor at MIT and former advisor to President John F. Kennedy. Her mother was sister of architect Richard Neutra. Susanna also had a sister.

Susanna was about to finish high school when she had a sexual relationship with her high school English teacher and ran away with him to New York. After returning, Susanna woke up one morning with the decision to commit suicide. “It was my task: my job for the day. I lined them up on my desk and took them one by one, counting” (Kaysen, 1993, p.17). Altogether, she took 50 aspirin, but beforehand, she called her (same-age) boyfriend and told him she was going to kill herself. When she went out to get some milk, realizing the attempt was a mistake, the police arrived at her home (the boyfriend had alerted them). She collapsed at the store, and was taken to the emergency room.

The doctor who forcefully advocated her committal to a mental hospital interviewed Susanna for only twenty minutes. He sent a letter to McLean Hospital stating that his evaluation was three hours long. He described her as having the following symptoms: immersion in fantasies; a chaotic lifestyle with no plans for the future; decompensation; sleep problems; depression; suicidality; immersion in fantasy; and progressive withdrawal and isolation. At the hospital, she was assessed as profoundly depressed, suicidal, and promiscuous, with no direction to her life.

During her stay at the hospital, Susanna described the difficulty she had making visual sense of patterns in objects like Oriental rugs, tile floors, and print curtains. Supermarkets were especially bad, because of the long, hypnotic checkerboard aisles. When she looked at these patterns, she saw other things within them. She adamantly denied that she hallucinated. She knew she was “looking at a floor or a curtain. But all the patterns seemed to contain potential representations, which in a dizzying array would flicker briefly to life.”

She also had some perceptual challenges with people’s faces. She stated “once you start parsing a face, it’s peculiar item: squishy, pointy, with lots of air vent and wet spots. This was the reverse of my problem with patterns. Instead of seeing too much meaning, I didn’t see any meaning” (Kaysen, 1993, p. 40).
Furthermore, she stated, “The world, whether dense or hollow, provoked only my negations. When I was supposed to be awake, I was asleep; when I was supposed to speak, I was silent; when a pleasure offered itself to me, I avoided it. My hunger, my thirst, my loneliness and boredom and fear were all weapons aimed at my enemy, the world” (Kaysen, 1993, p. 42).

During her two-year stay at the hospital, she experienced one, six-hour episode of depersonalization, where she bit open the flesh of her hand after becoming terrified that she had "lost her bones.” She talked about wanting to cut herself to see whether she would bleed to prove to herself that she was a real person. She mentioned she would like to see an x-ray of herself to see if she had any bones or anything else inside.

Throughout her stay, she had periods of depression and believed her parents did not understand what she was going through. They communicated little to her, and she felt as if they weren’t to be trusted. Susanna received psychoanalysis at the hospital but didn’t appear to get much out of work with her therapist. She talked about the “us against them” mentality of the residents and the nurses, but Susanna described as being close to one of the nurses. Her closest – and longest-lasting – relationships were with her fellow residents.

Question: If you have seen the movie or already read the book, do you remember the diagnosis she was given? Did this seem appropriate?

If you don't have familiarity with this memoir, what other information might you need to provide an appropriate DSM diagnosis? What diagnosis would you lean toward?

DRY - Treatment

Augusten requested to attend a specialized rehab that was designed for people who are gay and lesbian. This seemed to motivate him to attend and take part in treatment.

DRY fails to provide much detail about Augusten’s treatment, although there seemed to be a lot of group therapy, which is typical of most rehab facilities. His extensive history of childhood abuse, although identified as a factor in his drinking, is not discussed as part of his treatment.

Augusten talks a lot about AA attendance when he returns to New York. AA seemed helpful for him, but unfortunately, he also met at the meetings, a person with whom he became romantically involved. Given this person’s addiction to crack cocaine, Augusten eventually ended up relapsing on both alcohol and crack cocaine. He continued to have a problem with both substance for two years until he returned to AA and became sober on a permanent basis.

Eliciting and Amplifying Strengths DRY

These questions from Solution-Focused Therapy and Motivational Interviewing could be used to find out more about Augusten's strengths and resources and how these could be used to tackle his substance abuse.


1. How were you able to have such a successful career, despite dropping out of school so young and only having a GED? What qualities did you draw upon to reach your level of employment? How did you convince your employer that you were able to do this kind of work? How have you been able to be a success?
2. How were you able to survive the kind of childhood you had and rise above it?
3. The pain of this problem can affect many areas of your life. What aspects of your life are still intact despite the problem, such as relationships, hobbies, interests, employment, academics?
4. When have you been able to give up drinking or drugs, or cut down your use? How were you able to do that?
5. How have you been able to attract the friendships you have? What about you would they say you have going for you? How are you able to rely on them for support?
6. Motivational interviewing- What do you get out of drinking/What do you like about it? What are the not so good things?
7. What will your life look like when you are past this? What will you be doing/What will you be saying?/How will other people react to you?


1. How were you able to have such a successful career, despite dropping out of school so young and only having a GED? What qualities did you draw upon to reach your level of employment? How did you convince your employer that you were able to do this kind of work? How have you been able to be a success?
2. How were you able to survive the kind of childhood you had and rise above it?
3. The pain of this problem can affect many areas of your life. What aspects of your life are still intact despite the problem, such as relationships, hobbies, interests, employment, academics?
4. When have you been able to give up drinking or drugs, or cut down your use? How were you able to do that?
5. How have you been able to attract the friendships you have? What about you would they say you have going for you? How are you able to rely on them for support?
6. Motivational interviewing- What do you get out of drinking/What do you like about it? What are the not so good things?
7. What will your life look like when you are past this? What will you be doing/What will you be saying?/How will other people react to you?

BIOPSYCHOSOCIAL RISK AND RESILIENCE ASSESSMENT FOR DRY

Onset of the Disorder
Biological
RISK
• Family history of substance abuse (father)
• Family history of mental disorder (mother)
• Male
PROTECTIVE
Good Physical health

Psychological
PROTECTIVE
Lack of co-occurring disorder

Social
RISK
Physical abuse from father
Ongoing sexual abuse starting at 13
Maternal abandonment
Gay

PROTECTIVE
Was able to obtain his GED and have a high paying job

Course of the Disorder

Biological
PROTECTIVE
Good physical health

Social
RISK
Lack of family support
Gay

PROTECTIVE
Boss and co-worker are supportive of intervention
Has close relationships with friends
Continues to hold a well-paying job
Access to specialized treatment for people who are gay

Rationale for DSM Diagnosis for DRY

Axis 1: 303.90 Alcohol Dependence with physiological dependence

Augusten has displayed a maladaptive pattern of alcohol use, leading to clinically significant impairment or distress, as manifested by the following symptoms, occurring in the last year:
1. tolerance: a need for markedly increased amounts of the substance to achieve intoxication or desired effect (one liter a day of whiskey).
2. withdrawal (he is given Librium while detoxing to avoid physical shock)
3. the substance is often taken in larger amounts or over a longer period than was intended time (begins with intention to drink until midnight but keeps going until bottle is finished)
4. there is a persistent desire or unsuccessful efforts to cut down or control substance use (even when he has to attend to work responsibilities, Augusten is unable to stop his use)
5. a great deal of time is spent in activities to obtain the substance, use the substance, or recover from its effects (drinks every night and is unable to meet work responsibilities due to lack of sleep and hangovers)
6. important social, occupational or recreational activities are given up or reduced because of substance use (occupational problems due to use, threatened with job loss)
7. the substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (drinks even though he is allergic to alcohol and has to consume large amounts of Benadryl to prevent a reaction from alcohol)
• With physiological dependence is specified due to the evidence of tolerance and withdrawal

Axis II: V71.09 No Diagnosis
No evidence, at least in DRY, of a personality disorder, although this could be assessed further.

Axis III: Allergy to alcohol

Axis IV: Problems with Primary support: Poor relationship with parents who seemed to have abandoned him as a child; mother now suffers from a stroke

Problems with the social environment: enabling drinking friends, living alone, friend with terminal illness

Occupational problems: is threatened with job loss if he does not participate in treatment

Axis 5: 50

Augusten shows a serious impairment in social and occupational functioning, which indicates a GAF of 50. This would be lower if he did not continue to have a job that provides adequate income.

MULTI-AXIAL DIAGNOSIS FOR DRY

Axis 1: 303.90 Alcohol Dependence with physiological dependence

Axis II: V71.09 No Diagnosis

Axis III: Allergy to alcohol

Axis IV:
Problems with Primary support: Poor relationship with parents who seemed to have abandoned him as a child; mother now suffers from a stroke
Problems with the social environment: enabling drinking friends, living alone, friend with terminal illness
Occupational problems: is threatened with job loss if he does not participate in treatment

Axis 5: 50

Grateful acknowledgement to the contributions of Will Hayden, Erika Paz, and Dallas Williams.

DRY by Augusten Burroughs: Case Study

DRY is Augusten Burroughs’ second memoir and the sequel to RUNNING WITH SCISSORS. Augusten’s parents divorced early in his life. His father was a professor, who abused Augusten physically when he was drunk. Augusten described an incident at nine years old in which he had to jump out of the car his father was driving because his father threatened to crash the car and kill his son. On another occasion, his father burned Augusten on the bridge of his nose with a cigarette.

When he was 12, his mother sent Augusten to live with her psychiatrist. The adopted 33-year old son and former patient of the psychiatrist raped Augusten at 13, and he was sexually abused for the next three years by this man. By the time Augusten left the psychiatrist’s house at age 17, he had little formal education, having dropped out of school after sixth grade. He instead obtained his GED. Despite this lack in education, Augusten was able to work his way up, by his mid-twenties, to a high-paying job in the advertising industry earning $200,000 as a Manhatten copywriter.

Augusten had his first drink at age 12 when he drank a bottle of red wine. Between the ages of 13 to 17, he smoked marijuana and drank alcohol once a week. At age 18, he drank nightly, always to intoxication (five drinks or more). Between ages 19 to 20, he was drinking 10 drinks per night. He also used cocaine once every six months. At age 21 to 30, he was drinking a liter of Dewar’s a night and using cocaine once a month.

When the book opens, Augusten describes being unable to limit his drinking. “I would plan to drink only until 11 or 12, but it would never actually happen. The few times that I didn't drink for a night, or alcohol wouldn't have the desired effect of numbing, I'd be overwhelmed with emotions, usually grief, and it was just really upsetting. It freaked me out because I felt like a wreck inside, like my structure was rotting and alcohol was sort of the glue holding me together. In a lot of ways, I felt like it was the only thing allowing me to function. In fact, it was the opposite. I was able to function despite it.” Augusten drinks even though he actually has an allergy to alcohol, necessitating his taking several Benadryl tablets before imbibing.

Augusten’s apartment is filled with hundreds of empty Dewar’s bottles because he is embarrassed to be seen (or heard – the clanking bottles) disposing of them. Because of the bottles, he never invites anybody to his apartment. Augusten’s support network comprises his best friend Pighead, an investment banker dying of AIDS; his drinking buddy Jim, a coffin salesman; and Greer, his tightly-wound colleague. His mother had a stroke 10 years prior, which left her paralyzed on one side and wheelchair-bound. Augusten doesn’t visit, although e-mails daily. Although he feels pressure from her to take care of her, he believes, after her giving him away to be abused, she does not deserve more than this.

His alcoholism begins to interfere with his performance at work. He starts missing meetings, shows up late, and smells like alcohol. Eventually, his co-workers stage an intervention. His boss and his partner at work, Greer, propose that he go to rehab or risk getting fired. He agrees to go to a gay rehab clinic in Minnesota, the Proud Institute, for 30 days. There, he is given Librium while he is detoxing to prevent him from physical shock from the alcohol withdrawal.

After 30 days at Proud, Burroughs returns to New York and takes his recovery seriously, throwing himself into his work with renewed vigor, and attending Alcoholics Anonymous meetings and outpatient therapy. He is clean for awhile, but Pighead's illness and a relationship with a man Augusten meets at A.A. who is addicted to crack cocaine cause him to relapse. He not only drinks but now starts using crack cocaine and puts himself at risk by going to a “crack house” one night. Despite hallucinating spiders, he retains his employment, although it takes him two years to return to A.A., where he recovers once more.