Take two Prozac and don't call me in the morning. .

Sometimes fiction can illuminate a social or political issue more clearly than the best policy writing. In 1978, The Washington Monthly excerpted Samuel Shem's first novel, The House of God, which provided a wickedly funny inside look at the world of a first-year medical intern. In his new book, Mount Misery, Shem holds the psychiatric profession up to the same probing light.

When we meet our hero, Dr. Roy Basch, he is a month into his residency at the renowned Mount Misery psychiatric facility and gradually realizing that everything he thought he knew about treating the mentally ill is wrong. (To further confuse matters, his mentor, Ike White, has just committed suicide, but the hospital administration is insisting he died of a fatal disease.) Now, Basch is learning that treating a patient to the latest psychoactive cocktail, shock therapy, talk therapy, or surgical technique--or trying to force a patient into a certain category--does more harm than good.

Emerson's high walls and locked doors seemed sinister. Noting the "Split Risk" sign, I opened the door to my new ward, Emerson 2, Borderlines, with caution, shielded the opening with my body, back-flipped in fast and threw the door closed. It shut with a tremendous "wham!"

"Dickheads Slam Doors!"

The same sandy-haired young man as before. I went into a slow burn, wanting to respond, but stopping myself. About 20 other patients were sitting around the living room, staring at me. I saw the two tennis players. The normal, older man, in a crisp summer suit, was reading The Wall Street Journal. The younger, thin man--the manic one--was reading a tabloid and eating a carrot. He took a bite. In the tense silence the crunch seemed enormous. No doctors were in sight. The patients--teen to senior citizen, dressed from high fashion to rags, many with bandages around their wrists or heads or legs, one in a neck brace riveted into her skull, one in a wheelchair--seemed like so many wounded, shell-shocked refugees, waiting for a war to end so they could move. These were the dread "borderlines."

I asked the ward secretary where I could find Dr. Malik.

"The one with the carrot. Hall meeting's just about over."

This was a surprise. I stood and watched. He was speaking: "Like I said, Ike White killed himself. Nobody knows why. Hard to take. But we gotta face reality. Game's over for him, but not for us. I'm here. You wanna talk suicide, I'll talk suicide. But do sports! Catch ya later."

Malik walked over to us. He was wearing a shortsleeve white shirt and a slender red tie, khaki trousers, and well-worn Nike running shoes. His wiry athlete's body seemed too small a container for his energy. He had jet-black hair, parted carefully and slicked up and over in front. In his long tan face, his hawk's nose was bridged by black-framed glasses whose lenses were tinted amber. We shook hands. He was large for his size and, though tight with tendons, gentle. An athlete's hand.

"I saw you playing tennis yesterday. I thought you were a patient."

"So y'think there's a big difference between doctors and patients? Sometimes your patients are better than you" He fixed me with his eyes. I had a strange sense of being seen into. He glanced at my suit. "Boy, you got it bad."

"What do you mean?"

"You know what I mean, doncha?"

"Sort of," I said, sensing him sensing my discomfort wearing a suit.

"So if you know what I mean, you don't ask what I mean. To be a shrink you still got a lot to unlearn, like all us kids who went to med school. Specially us hot-shit high-achiever Jews."

I wanted to ask what he meant but stopped myself.

"You stopped yourself. Good." He took another bite out of his carrot, dosed his eyes and chewed carefully, savoring it.

"What's with the carrot?"

"A carrot a day keeps colon cancer away" I laughed. "No joke. Studies have proved it"

"And just where is it you put the carrot?"

"Ha! Haha! Good. So. You play any sports?"

"Tennis, basketball, and golf."

"You do okay in psychiatry as long as you keep playing sports and use what you know from sports. Anything else before I show you what's what?"

"I was surprised you told them about Ike White. I've been trying to figure out what von Nott meant by a fatal disease."

"That's bullshit. Lloyal means he was biologically depressed, but depression never has to be fatal. Never. All this fatal-disease bullshit is so they don't have to admit they killed him."

"They killed him?"

"Places like this kill guys like him right and left, and a lot of the dead don't even know when they're dead 'cause their souls die first."

"That seems pretty bitter--" I started to say, but then stopped, for Malik had tears in his eyes, ambertinted wetness. One tear, escaping from under his glasses, ran down his cheek, translucent, losing form as it ran, leaving a trace behind, like a snail's. Looking away, he chomped his carrot mournfully, giving out several forlorn crunches. He gulped down sobs, his Adam's apple shuttling up and down his thin neck. I asked, "`You must've known Ike really well?"

"Nobody knew Ike well" He removed his glasses, squinted like a mole in the light, and wiped away the tears with the back of his hand. "Nobody alive knows a suicide at all."

"Why'd he kill himself? Is there some dirt, some secret? Why?"

"What can I tell you? Psychiatrists specialize in their defects."

"And Ike specialized in suicide?"

"Wrote the classic papers, yop. Maybe we'll find out more, with time, and the more you find out about a person, the more sense they make, never less. Lloyal was crushing him. He died of death." He blinked, looked around in puzzlement. "Why'm I preaching to you? Jesus! C'mon--"

"Wait" He waited. "If the other shrinks are lying about him killing himself and you're telling the truth, aren't you gonna get into trouble?"

"So what else is new? They don't like me teaching you new guys, `specially not here on Blair Heiler's ward. Eleven months of the year Heiler terrorizes these patients, so nobody else wants to deal with the mess in August when he's on vacation in Stockholm. Sucking Nobel Prize butt."

"Terrorizes!"

"Yop. So. Emerson Two. Know anything about it?"

"It's the borderline ward," I said. Ike had given me a lecture on borderlines, patients who were on the border between normals--or neurotics--and crazies--or psychotics. The lecture was based on the DSM--the Diagnostic and Statistical Manual--the bible of psychiatric diagnosis published by the prestigious American Psychiatric Association. The DSM described borderlines as suffering from a pervasive instability in interpersonal relationships, self-image, and feelings. The official diagnosis of Borderline Personality Organization, or BPO, was defined by 13 Krotkey Factors, created by the borderline world expert Dr. Renaldo Krotkey. Dr. Blair Heiler, local borderline expert, was a follower of Krotkey. Some of the Krotkey Factors were: impulsivity (BPOs were dramatically impulsive about sex, shopping, gambling, substance abuse, reckless driving, binge eating, etc.), fear of abandonment, unstable relationships, suicidal or self-mutilating acts, mood swings, feelings of emptiness, and a fierce, withering rage. Borderlines were emotionally labile, sometimes seeming completely normal, sometimes really crazy. They could change in an instant, for no clear reason. Most borderlines were women. Ike had painted me a dire picture, and now I quoted Ike to Malik, "Borderlines are hell. They make your life as a psychiatrist miserable. They're almost impossible to treat. Borderlines are the worst patients in all of psychiatry."

"Yeah, well, don't hold your breath, but borderlines don't exist." I laughed, thinking he was joking. "No joke. Problems with relationships, self-image, feelings, impulsivity? We all got that! Your job is to resist brain-washing as long as possible and just try to help these poor people. Being lied to about Ike's death has got 'em bullshit! All three floors of Emerson are rumblin', ready to blow! Try to help 'em and play sports! Listen up."

Heiler had left the ward full. Malik said that most of the patients would be better off out of Misery and that we would discharge as many as possible. Given the fact that insurance companies were now dedicated to not paying out insurance, this wouldn't be difficult. The ones who needed to stay, he'd go to bat for. He started dialing a phone.

"How do you get insurance to pay for them to stay?" I asked.

"Allora? Testa di catzo!"

I turned, and then realized once again who it was. I'd just been called a dickhead in Italian.

"Thorny," Malik said, "meet the new resident, Roy G. Basch."

I looked into the eyes of the tall, sandy-haired, baby-faced man. He wore jeans, suspenders, a blue work shirt, and bow tie. A row of fresh sutures, like a tiny barbed-wire fence on his forehead, overlay other old scars. I shook his hand. k was as boneless as Ike White's had been the night before.

"What's that?" Malik asked, talking into the phone. "You ain't gonna pay for another day of Mr. Thorne's stay here in the hospital?"

"They gotta pay or else I'm dead!" Thorny said frantically.

"Yeah, well, he's extremely paranoid and dangerous and--" He listened for quite a while and then said, "How can we prove it? Well, Ms. Tillinger, he just told me that unless you let him stay he's gonna come right down there to your office with a gun and-- That's right, a gun, and in his words, `blast them insurance fuckers to smithereens.' Now, where exactly are you located, dear?" Covering the receiver, Malik shook with laughter. He said, "managed care, I love it. Basch, go talk to Thorny." I hesitated. Malik made shooing-away motions, saying, "Go, go. Move."

Thorny was glowering at me. He walked away and sat down. I felt a strange fear. Malik hung up. "What am I supposed to do with him?" I asked.

"Be human," Malik said. I stared at him. "Human? Human being?"

"But he's so pissed off, suppose I say the wrong thing?"

"Think these people are fragile? Just try `n' change 'em. But hey, I know you're scared. I was too." His eyes locked in again. I felt a kind of rush, a "click"--he was the first person since I'd been there who had talked to my fear. "Weird, ain't it," he said, "to be so scareda just sitting down and talking to somebody? Image is a killer, and self-image is a killer killer! So listen up, if you need me, call" He squeezed my arm and walked off, stopping to pick up a piece of litter.

"Dickheads Save Planet!"

"Yeah," Malik shot back, "for assholes like you."

I walked over to Thorny, thinking about how to be human.

"So, Dr. Dickhead, tell me about yourself." Thorny said.

Uh-oh. Surely this is backward--I was supposed to be asking about him. "I'm the new resident" I felt a sharp pain in my palm. I was clutching my key ring so hard the keys were biting into the flesh. "You?"

"Got here a month ago from New Orleans. My daddy's rich, made a fortune burnin' trash down Cancer Alley. Calls himself the Burn King of the Bayous. I did okay till I was eighteen, `n' got sent north to Princeton. Lasted but three months. You look kinda tentative, Doc. Scareda me?"

I was, but I wasn't going to let him know it. "Nope!"

"Sure is sad Ike White killed himse'f ain't it?"

"They say he died of a fatal disease and--"

"Oh, pleeeeeze!" he said, disgusted, getting up. "Hey, patients! Hey, borderlines!" They all looked at him. "This new doc is pitiful! We got ourselves a real loser in this Roy G. Dickhead Basch!" He walked away.

Not a good start. If this wasn't a borderline, who was? Humiliated, I decided to interview another new patient of mine named Mr. K., whom I recognized as the kindly old gentleman who'd been playing tennis with Malik. I found him on the sun porch, finishing The Wall Street Journal. We had a wonderful talk. He was, he said, the last survivor of an old Yankee family. Only recently had things gone awry. His golden retriever, Duke, had died. His son had come out as gay. His wife was drinking again, and his daughter had run off with a drug dealer. He'd come to Misery a month ago for a rest.

"You seem so sad," I said, touched by all this recent misfortune.

"'Tis cause for weeping, yes." He started to cry.

"We'll discharge you soon. Maybe even next week."

"That would be grand!" he said happily. "Thank you for your time."

Time that had flown by. I was excited at this, my first good interview of a borderline. At the nursing station I told Malik about it. The head nurse and social worker listened in. I said that Mr. K. seemed about ready for discharge. When I stopped, no one said anything.

"Ever hear of a mental status exam?" Malik asked. Someone giggled.

"Oh shit," I said. "I blew it?"

"Big-time. Let's go." He led me back to Mr. K.

"Gonna ask you two proverbs," Malik said. "Tell me, Mr. K, what do people mean when they say, `A rolling stone gathers no moss?'"

"They mean that I have never been happier!" he said, and started to sob uncontrollably, on and on, in horrific pain.

"And, `People who live in glass houses shouldn't throw stones'?"

Abruptly he stopped sobbing, began laughing hard, and said, "It's a big cry, a big big cry!"

"And who's the president of the United States?"

"Herbert Whoever."

With Mr. K. listening, Malik told me that when Mr. K. was six, driving with his mother, a car hit them and she was decapitated. Her head landed in his lap. "At ten he was institutionalized. From then on, because he's rich, he was assaulted by whatever treatment was at the leading edge of American psychiatry: insulin shock, cold water dousings, being strapped into the Benjamin Rush restraining chair and given emetics and whirled around 'til he puked his guts out, enemas and high colonic irrigations to get it out from the other end--"

"Woo-wheeee!" Mr. K. said, shaking his head in amazement.

"Enough electro-shock to light up Iowa, the most toxic drugs ever concocted, two first-rate psycho-analyses--one for each hemisphere, for the left, Freudian, for the right, Jungian--and a prefrontal lobotomy" Malik made a stabbing motion up through his own eye socket, and then a slashing wiggle. "An ice pick, stuck in his brain?"

Sickened, I said, "Thank God they don't do those anymore."

"Oh, it wasn't that bad," Mr. K. chided.

"Oh, but they do!" Malik said. "Lobotomy's making a comeback! Check out Archives of General Psychiatry, June 'ninety-one. Big article proving that lobotomy is the treatment of choice for refractory obsessive compulsives."

More sickened, I said, "But we had a great talk, Mr. K. didn't we?"

"Thumbs up!" Mr. K. said, putting his thumbs down, smiling sweetly.

"Yes, you did. Luckily, they botched his lobotomy. Left half a frontal lobe. Lloyal's his therapist. Fifteen-minute sessions, a hundred twenty bucks a shot. They talk finance. Mr. K's trust fund will keep him in Misery till he dies. He's been here forty years."

"But he was just transferred over here to Borderline yesterday."

"Heiler had an empty bed. Empty beds mean stalled careers. He `n' von Nott agreed Mr. K. needed a trial of BPO with HFL--Half a Frontal Lobe."

"That's quite funny actually," Mr. K. said, chuckling normally.

"They can't touch you," Malik said. "As a shrink, Roy, you got to be able to tell when something's organic--medically treatable--as opposed to mental. You don't treat brain tumors with psychotherapy. Proverbs can help find out which is which. Read Mr. K.'s chart. It's a memorial to the harm done by shrinks trying to fix people. Now we gotta protect him." "From what?" "This." He spread his arms. "All this. The more I see, the more I think that if all shrinks in the world were to die of heart attacks at once, all the world would be a helluva lot better off."

"Including you?"

"If and when I act like a shrink, yeah."

"But you are a shrink."

"You gotta know it to let go of it. You tell me if and when, okay?" I nodded. "And when I'm gone in a month, protect him from Blair Heiler and you."

"Me?" I asked, stunned. "You don't know what you're talking ab--"

"Kid, you're gonna go for Heiler like America goes for stars! C'mon, we got Case Conference. Heiler set it up before he went on vacation."

Malik left, but I couldn't yet. A cloud darkened the quiet porch. I turned back to Mr. K. In silence, he was weeping. Two glints of tears were running sadly down his old man's old damaged man's cheeks. I felt really bad. "I'm sorry, Mr. K.," I said. "Are you sad, hearing all that?"

"Hahaa!" he said, his laugh crackling and high-pitched, like a child finding a favorite toy, say a stuffed zebra. "Doctor, I've got some advice for you: Always keep a low center of gravity sometimes."

"Deal," I said, relieved.

Laughing, he gave me a thumbs down and a high five.

Case Conference was designed to try to get a fresh look at a problem patient by bringing in a world expert to talk things over. Waiting in the conference room was Dr. Errol Cabot, the world expert of the day, his world expertise being the drug treatment of mental illness. Errol was a chunky 35-year-old man with a square-jawed flat face and eyes that seemed to bulge out of a sea of thyroid. The drug doctor was so restless and hyper he always struck me as being on drugs. His dark red hair was cut back like the helmet of Winged Victory, and he wore a long, white lab coat.

With him was his protege, a new first-year resident named Win Winthrop. I knew Win from medical school. Though fat, he was energetic and optimistic, with the keen intelligence I had always associated with people with his fiery red hair and freckled, alabaster skin. Win's father was a Boston Brahmin, a well-known lawyer at Hale and Dorr, and he had been disappointed in Win's choice of psychiatry, for he had been hoping against hope for the only honorable medical specialty, surgery. After only a month Win, like a dog with its master, had become much like Errol: both were hyper and manic with eyes wide; like boys eyeing an electric train set; both had their red hair cut like Prince Valiant and both were bulky under long white lab coats. They were rocking in their chairs as we entered the room. I was to find that Errol--and Win too--had two traits that would prove remarkably useful as they threw drugs into people: unawareness of self, and unawareness of others.

That day the patient was Mary Megan Scorato, admitted several weeks before to Emerson 1. For those weeks, Ike had been her therapist. I remembered that she was the "acutely suicidal patient" Ike had needed to see the day before as I'd left his office. Mary Megan was one of those "salt of the earth" people whom everyone loves, a kindhearted woman of Irish descent married to an Italian who, in her weeks on Depression, had taken to "mothering" all of us, patients and doctors alike. Mary Megan baked cookies for us all, listened to other depressed patients' problems, cleaned countertops, and did laundry. Everybody loved her. How could you not?

Yet she herself remained hidden. A woman from a poor Irish family, she'd worked her way through secretarial school and had become an assistant director of admissions at Harvard, over an hour's commute away. Institutions like Harvard always have a warm-hearted type on the front lines, protecting the hard-hearted higher-ups, and Mary Megan was it in Admissions. She had had her share of suffering: married at 40, she gave birth to a baby with Down syndrome. Now a six-year old, the boy was severely disabled. Mary Megan was a hefty woman, but she had lost her appetite, begun eating very little, and lost a great deal of weight. People said, mistakenly, that she "looked good." Two weeks before she completely snapped. She was picked up by the state police on the side of the interstate, weeping hysterically, threatening to throw herself into the traffic. As they were coming home from vacation, the family's luggage had blown off the roof and her six-year old's new parka had flown away and reappeared crucified on the front grill of a trailing ten-wheeler. Since then she'd been actively suicidal. But something didn't make sense. Why should luggage falling off a car and a parka on the front of a truck plunge a fine, by-all-accounts cheerful woman with lots of friends at work and home into suicidal despair? No one, not even Ike White, had been able to find out.

"Okay!" Errol said as we sat down, before Mary Megan was brought in. "Let's go. Win and I have read the chart, so we all know the case. First, diagnosis. It's absolutely clear this gal is a BPO with Ano--"

"First," Malik said, "we talk with her."

Errol's jaw dropped, as if this were incredible, for a doctor to actually talk with a patient.

Mary Megan Scorato came in. Her freckled milky complexion was marred by dark bags under her eyes and slack skin around her mouth. The edges of her lips turned down, as if she were on the verge of tears. Her auburn hair was unwashed and halfheartedly in a bun, ends escaping out and hanging despondently down, ends she didn't brush out of her eyes. Her clothes, usually neat and clean and perky in the way that an old-fashioned, good mother's kitchen clothes are perky, were rumpled and too big for her thinning body. She nodded to Errol, Win, Malik, and me and sat down. Malik explained that we would talk.

"This morning I wrote a little poem for this conference," she said.

"What meds are you on, sweetheart?" Errol asked.

"Dr. White was so kind and good, I wrote a poem."

"What meds worked best in the past, gal?" Errol asked.

It went on like that, Errol talking drugs and Mary Megan talking poetry. Mary Megan got more and more subdued. I felt for her. Finally Malik said, "You okay, Mary?"

"No I am not! I came here to read my poem for Doctor--"

"What about anticonvulsants, honey?" Errol asked.

Mary Megan stared at him and then took a green piece of glass out of her sleeve and held it to her wrist. "Let me read my poem or I'll cut myself!" Her thin cheeks made her eyes seem huge.

"Read," Malik said. "We'll listen" Mary read her poem, ending with:

"We all imagined his hesitant, stammering manner

Merely concealed his heart's strong core,

But he had his misery, his hesitant stammering manner,

and nothing more."

Stillness. She's gotten him exactly right. Errol and Win kept rocking in their chairs, but said nothing. Mary handed the piece of glass to Malik.

"Beautiful," Malik said, "and true. Can I ask you a few questions?"

"Yes. If you can be kind, like Dr. White."

"I'll try," Malik said. He talked with her for a while, and then the strangest thing happened. Later I couldn't recall how it came about, but after just a few minutes of their talking, talking as if they were old friends meeting after a long time, talking about her Down syndrome son and the parka crucified on the truck, Malik asked her something that seemed completely bizarre:

"Tell me about your other son."

Mary Megan sat up in shock, her eyes wide. "My other ... ?"

"Yes. The one you lost." I had no idea what he meant. Mary Megan had said nothing about another son. I felt a kind of "click." I waited.

"Oh, God!" she said, and began to weep softly, and on her tears rode a story none of us had ever heard from her. Thirty-one years ago, when she was seventeen, she'd been forced into sex with a neighbor and gotten pregnant. She'd told no one but her mother, who demanded that she give the baby up for adoption. Finally Mary agreed, on one condition: that the Clarissan nuns taking the baby let her see it just once. The Mother Superior agreed. She gave birth to a boy. The nuns never let her see it. Every year, every single year on his birthday, she would think of that baby boy and wonder where he was, and what his life had become. "A year and a month ago," she said now, "on his thirtieth birthday, the phone rang. I picked it up. A man's voice asked, `Is this Mary Megan O'Toole?" I knew at once. My heart seemed to tear loose inside me. I said, `Yes it 'tis.' `Well ... I'm your baby boy."' She wept frantically, searching for tissues. Malik handed her a box. Calming down, she went on, "We met a few days later, and ... he said he wanted to meet just the once, no more. I told no one, no one knows this, no one a'tall, not even my dear husband Joey. I never even told poor Dr. White. I was okay for a year, but then, this year, without him, when that day came 'round ... I could not go on. I couldn't even eat."

"Anniversaries are killers," Malik said. "You had an `anniversary reaction'--it's totally normal. And why didn't you tell Dr. White?"

"He seemed too ... vulnerable? And he didn't ask, like you did."

"You feel okay about telling us?"

"I do. You have a kind face. Thank you."

"Now that it's out, we can help you to heal the wound."

She wept again, quietly. I felt moved, awed even, by Malik's way: so simple, so there with her. She sniffled. "That would be fine. Thanks."

Mary Megan left, shutting the door quietly behind her.

"Okay good great," Errol said loudly. "Now let's do some real work!"

He and Win then discussed the "case," fitting it brilliantly to Borderline Theory, concluding that the diagnosis was BPO with A and B--Anorexia and Bulimia--even though Mary had explicitly denied bulimic vomiting. And wouldn't you know it but BPO with A and B was a particular diagnosis Errol just happened to be world expert in! Not only that, but by sheer coincidence he was also the world expert in the drug to treat it! "The treatment of choice," he said, "is my experimental drug amyoxetine--brand name Placedon. Brought it back from Bangkok--in my backpack. Placedon makes Prozac look like popcorn. We may need to add my other experimental drug, Zephyrill." While these names were enticing, as if, if you did these drugs you'd be partaking in an encounter with two of Babar's lost children, I was appalled at this, a diagnosis and treatment totally at odds with her obvious and what seemed to be normal grief.

"The woman is going through a normal grief reaction," Malik said. "If we can keep her off drugs, she'll pull together just fine."

"This is for the benefit of the new residents," Errol said, glancing at me and Win. "There's never once been a controlled experiment that showed that talking to patients does any good at all. Any effect is placebo effect. You residents shouldn't waste your time learning how to do this mumbo-jumbo, 'cause there's no `it' to do. So Malik got her to tell a story, so what? Won't help. Like pissing in the ocean. There are no `psychosocial' factors in mental illness. If it's mental illness, it's biochemical, and vice versa. Save her a lot of grief--give her Placedon."

"Thanks for sharing, Errol," Malik said, "and now go fuck yourself."

"So," Errol went on, as if Malik hadn't said what he had said, `To get these experimental medications, she has to be in our new research study." He took out a lavender form and got up. "I'll get her informed consent."

"She refuses all drugs," Malik said, rising. "Thanks for stopping by."

"Don't worry, we'll get her to sign."

"She won't talk to you, guaranteed."

"We'll get husband Joey to sign."

"Not without her permission."

"She's not competent to give permission. She's a borderline!"

"And," said Win Winthrop, "bulimic. She deserves a trial of Placedon."

"After she's on it, we'll get some of her blood," Errol said. "When her level's in the therapeutic window, she will be competent, and then she can decide rationally about going off Placedon no problem thanks."

Malik picked up Mary Megan's chart and reading aloud as he wrote, "Patient is mentally competent. Patient refuses all drugs."

Red-faced, Errol rose and said, "Know what your problem is, Malik?"

"Maybe that I think you're a neo-Nazi?"

"Your problem is you're nuts and you should be on medication!" They hurried out.

"Wait!" Malik shouted. "When are you gonna study drug compliance?" He turned to me. "Know what they don't do?" I asked what. "Sports! C'mon."

In the nursing station, as he changed into shorts for his morning run, Malik said, "Don't get me wrong, I'm not against using medication. I use it, if it's right to use. But all the studies of compliance show that patients don't take their drugs fifty percent of the time, and that the only reason they do is if they have a good relationship with their doctor. And guys like Errol are terrible at relationships. Which is one of the two reasons they specialize in drugs. Walk me out." I followed him outside.

"What's the other?" I asked, squinting at him in the bright sun.

"Money. Drug-therapy guys like Errol see six patients an hour, at seventy dollars a pop: four hundred and twenty dollars an hour. Talk-therapy guys see one an hour, at a hundred bucks." He stretched his quads, pulling a bent leg up behind his back so that, with those amber lenses straddling his beak nose, he looked like a wise, hip stork. "Talk therapy is dying. The drug cowboys are taking over. They use drugs to stay away from being with people. It's easier than being human with that kind of suffering. Other than drugs, the only way to make a living as a shrink is to write some bullshit self-help book. I'm thinking of writing one called `Anorexia Digest."'

"But how did you know, I mean about the other son?"

"Dunno. When she talked about that parka, crucified, I picked up somethin', like `lost son.' So I took a shot, got lucky. Sometimes people don't know that on anniversaries they crash. Just to name it helps a lot."

"It's so sad! Every year, for thirty years, on that day, she's wondering where he is? It blows me away."

"Yeah. Ike's suicide for her, for all of us, is a big `Fuck you!" He signed. "So now you see all the bullshitology around `diagnosis."'

"Isn't diagnosis important?"

"In psychiatry, diagnosis comes last."

I felt confused and overwhelmed. Everything this fanatic was telling me was the opposite of what I'd been taught about psychiatry before.

"Here, sit," Malik said. "Listen up." I sat on the lush, close-cropped grass, staring at Malik's tank top, on which two lambs were holding hands over their heads in triumph, and the acronym L.A.M.B.S. "This is a BPO ward. But check out the diagnoses: BPO with A--Anorexia; BPO with B--Bulimia; BPO with C--Catatonia; BPO with D--Depression; BPO with M--Mushrooms "

"Mushrooms?"

"Just checking. So Blair Heiler keeps trying to fit people into BPO, but they won't fit. So he keeps adding letters. One of these days he'll admit an adolescent with BPO with Z--Zits"

"Why does Heiler try to fit people into diagnoses?"

"Money and fame. He's a protege of Lloyal von Nott, world expert in money. He gets Lloyal to give him a ward for BPO. He gets drug money to study the Krotkey Factors to diagnose BPO. He finds that BPOs fit the factors! Quite a coincidence, eh? He gets more patients, with more BPO. Becomes world expert in BPO. Fame, money, climbing the greasy pole of academia. Heiler's in a catfight with his rivals at McLean to corner the market on BPO. Meanwhile he terrorizes these patients--which makes 'em act like BPOs! He publishes, they perish. Lotta suicides on the ward. Which is another Krotkey Factor: BPO with SS--Successful Suicide. And BPOs don't even exist. They're just people, right? We coulda got any diagnosis we wanted outta Mary Megan, depending on which diagnosis the world expert we called in was world expert in. In psychiatry, diagnosis comes last"

"What comes first?"

He put a hand on my shoulder. "Roy, you're gonna think this is crazy. In psychiatry, first comes treatment, then comes diagnosis"

"That is crazy," I said. "It goes against hundreds of years of medical science."

"You think this is a science?" he asked.

I didn't know what to say. For a while I stared at a duck carving lines on the still lake. Finally I said, "I don't know, Malik. You sound pretty cynical."

"Think of Mary Megan, her face when she took out that piece of glass. That was the face of terror, right?"

"But this, you, what you're saying, it's nothing like my month with Ike. This is not what I expected"

"Good. That's the first real thing you said. Listen up: all you gotta do to learn is keep your eyes open, your fly zipped, your feelings up front, and ask for help. Don't read any bullshit articles. Don't read, do. See. Feel. Do. And see everything in Misery in terms of Ike's suicide." He turned on his Walkman. Aerosmith!" he cried. "Steven Tyler is my God!"

He started to plug the earphones in. "Wait," I said. He waited. "Why are all these experts denying their feelings about Ike?"

"'Cause they mistake having no feelings for being smart." He trotted off.